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Waste Tire S64ky & Inspection Repol"iftlInspection Report Number <br /> State of California <br /> -iG7Li CIWM13181(New 04104) Survey Form - Page 1 I 1 1088016 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Busirl, Inspection Details <br /> TPID- ', q 3 I o� L(?J ' Inspection Type (Fill one) <br /> Site <br /> Site Suffix: (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalQ t-t`n �QO� If Referral,choose referral type(Fill one) <br /> Son �U� <br /> Identifier: 1 y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector ` <br /> `,C.ner� l,oY tr�ac�lon Nohile. EQWp i _ <br /> Physical Address 9 ( L�J <br /> j- <br /> I Kr►� ►an huc.us I <br /> L0 Frank We-s+ C_%,(._ <br /> i <br /> Street =09 Inspection Date <br /> CA g5Zo <br /> � `,to c,kt or, 6 <br /> State Z/P Coc Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> r Outs 11Sho o Fo c emon L --. <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Cunt(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> �7PS Latitude W � 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — I 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 I® Other YoYd , <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments KGtAtl1't¢. V) -this dam. -NneO o i <br /> n-o - <br /> �.J n W cA. <br /> rot OTR tlsgd sore d on s�t�,-_ est vefri,cle are -tgke�c, <br /> -i-0 -CPS aCCL\S"aoh CDS r er�orrns �_ry►cc an 1�2 <br /> s V v eSy lewed • �AII 'J\ \Ccc�n wrks or are45 C9nCer r7 - <br /> InsInspection Form Included: (Zoe <br /> pIF <br /> Comments Included: <br /> Business Rep's Signature Phone Number I ector's Signature C Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1E XI A, MI I P L I E. i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> d <br />