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I <br /> Waste Tire SL. .y & Inspection Report spection Report Number <br /> :35 8 State of California <br /> B 11 - 1088017 <br /> California Int grat d Waste Management Board Survey Form - Page 1 <br /> Part A- Survey__ BLUE OR BLACK INK PEN <br /> Busirn2ss flrofileAw- <br /> Inspection Details <br /> TPID- O - Q Inspection Type (Fill one) <br /> �l <br /> Site Suffix: ( � 0 W 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalSQ n TOG ul n COUYIf If Referral,choose referral type(Fill one) <br /> Identifier: y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I _ ` <br /> uCV T-tin - Brower Co. L-LC. i _ <br /> Physical Address t ' Kr�sf�Un U. os <br /> "T !oy rite_ Ct. - <br /> , <br /> Inspection Date <br /> I Street crk-to n CA 95 21 5 ,Cit, State ZIP Code Time InTime Out 1 <br /> Business Rep Title 0 AM j� AM <br /> Q .® PM ' I �/ 0 PM <br /> !.� -,gin hz r• <br /> 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 /> I. Active 0 Passenger G Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> - - -- <br /> Bysiness Type (Fill all that apply) - <br /> 0 New Tire Dealer 0 Auto Repair ® 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 <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste TlreiHaulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle % <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 10 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> i0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> j 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 <br /> Apotax Z-q w os�x/, �-1Ye.� r��ec��n-_s_d"Q_• -FckC-\ON u-`%es M C v -rf' C� <br /> -Tkre Se.-vy►c - CJT ,/2�reod��,_T� u)aS -'titre rernoyal I-ELT rManl <br /> rein-,LcQ Iota <br /> Inspection Form Included: 0, <br /> IJ <br /> Comments Included: 0, W- - _- - - f e N <br /> ..Business Rep's Signature Phone Number I ector s Signature - - Phone Number -i <br /> X � � 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � /l M P L E 1 � 3 ' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />