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Waste Tire Sul >.y & Inspection Report Inspection Report Number <br /> State a California Survey Form - Page 1 3 9 - 01 4 $ 7 3 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - —7 Inspection Type (Fill one) <br /> Site Suffix: I 3 8 p� / 1 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s(wk �Toac wv? C("Lu CHP ®CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> T$ � Trkck Se ✓ c, I Pe jqa' Z <br /> Physical Address 3 0 <br /> A/t%tVf� - Y% <br /> ( Inspection Date <br /> �� �,` Ck, .S2 <br /> ►UC n io Time In Time Out <br /> Business Rep fo s 1 1 � Title O AM O AM <br /> t <br /> I lei 11 tLU Vi ki e-1,11, O PM O PM <br /> f Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' ® Active 0 Passenger 0 Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> G PS Latitude 0 Hauler ! 0 Indoor <br /> 0 <br /> Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber /� <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other �Irbt( k &&gait- C Qav-vf({, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCCIEMINT STATUS. . <br /> _............... _ <br /> V =A HA LING AND MAl5fll'AST Itf"w»lWiR111M.RNTB. Q NQtfcs Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Complltlttt:e:Deadline <br /> 00 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements pAtp m I I <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days 1R6quired for NOV orEX77 <br /> 0 ! 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years +' <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ( 1ttifert tl f CIWMB Snforcemsnt <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1L t�, >rtmtshi No Vi,�istidtts <br /> 0 ® Other: § ��t{ s�•+ '. e+t'LQ��" S�If'CEv�t�tCallUn lyhr hCtLder —.— <br /> Comments T�e S <br /> �ic��d t� � �X peg ✓tnUn+lt 6 y 5M -r,re rn Maw, a . tiUo✓,k 0 rde,-,; <br /> fvr tlrec, be +'etreQds) 1Q�-+ by 1jcjjer-j 1,a I-Pilb#or, iovDites . Ptj 71)1 41 oil <br /> v4rk arde►- jnvoitceS . #ct Jer h use CmM 6 1 KO getr-,eci e,- Loco cuict mcti&fzt.in <br /> CfJ f3F ltldoice vikilie I'aLdirt , MaiyLtaiY1 jrlvoiCeS ori Sire. AIA- ,3 -eaf5 •- <br /> Inspection Form Included: 0 /, J � < <br /> Comments Included: 0 <br /> usl ass Rep's S tune Phone Number pector signature Phone Number <br /> INSTRUCTIONS ON BACK :' °" l LST111213162081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />