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Waste Tire4m & Inspection Re zpection Report Number <br /> -.IBI'I�i' 1 State of California <br /> 1 Cgrated 1(t eManage) Survey Form - Page 1 Il - 1088206 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i ' - I 0_1 �- - <br /> 0 � Inspection Type (Fill one) - <br /> Site Suffix: V Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CAr\ �0 (. U11"1 <br /> n Coup <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other I <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Address —1 i -} Gn Lu CGS <br /> �rIJ 1 <br /> zqI 5. 1�iGtiwo�, 9� i <br /> Street <br /> Inspection Date 0 <br /> Sock+on _ CA q Z 15 <br /> Ci1v State Z/P Cod,- Time In Time Out <br /> Business Rep Title I O AM Q AM <br /> V-�'UrChcisln5 Q PM L O PM <br /> T _ - <br /> 4 )� 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 /> ® Active d Passenger (9 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck Nr� <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other I p _..C_r n- «C'Fo_j <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / T / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ` (� - <br /> ut1 ( &_r TOr 11 t ' W I me ,q5t_ r].cii-e <br /> cernerC11 of15cc mosfi IIg61 dut tr,r1 AAon <br /> otc1�-uQ �'�re� . FcaCl t�y LA%_ 5 I �06 -C,mrwt-YcIe-, Tire <br /> J ` �-I�-te- MS 46r <br /> f ( <br /> 4;;�-� �fe 2�v1 ce e al . t t nc�r T t� ��v a► a1c,\e c1' WI <br /> r� <br /> Inspection Form Included <br /> Comments Included. i Business Rep's Signature Phone Number Ir ector's S 6 Phone Number <br /> I p� 9 9 >� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, '/ I 0XI AIMAIMI P I L 62081 I 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />