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`-= Waste Tire Sr ey & Inspection Repo* Inspection Report Number <br /> _ �a3a;t:2i State CIWMB California Il - 1- 088242 <br /> 0410 <br /> California In egrat d,81 Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_ - - BLUE OR BLACK IN_K PEN <br /> Business Profile Inspection Deta <br />} <br /> 1TPID- ' I I - Q Inspection Type (Fill one) ., <br /> Site Suffix _[4_F1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r J IJq U 1 1'� CoU h r If Referral,choose referral type(Fill one) <br /> SQn <br /> Identifier: C1 y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J U <br /> I Kr4r'1 Lucrls I <br /> I 11�`by E . yraves ud . I <br /> Street Inspection Date <br /> i M Gn+C C Cx GA 9533r. <br /> I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title Hi , AM O AM <br /> t� PM m ' QPM <br /> r t Von n , O u1 h.e r , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 01 <br /> (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 /> 0 0 Closed 0 Altered <br /> GPS Latitude m , 0 Hauler 0 Indoor <br /> Inactive 0 Truck N/A <br /> Longitude — <br /> FT -0 ®0 Planned 0 OTR *A l 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ---LU <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 /> - —Dice Station 0 Hauler ® 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 00 Notice Of Violation 0 Extension <br /> 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 1 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 1 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 I 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: § I - - <br /> Comments RoU}1n�. _VY1 p2C,+ton r Orme -}hts ddk+e -t1x �ol�r,W.lr1 _W. ) n <br /> No -}tre5 5i-ored Gr 9 ryP.ra --P_d on='A-c No YnoyQ -\N1--yl 10 „QC\:fie- <br /> hate teen \eneroAed �-tnc0\ 2_60-7 _� +ye; tare aer-;erct+eCA re�-ain <br />} c <br /> tln�tr r �v <br /> + n1 Rec y,,,.Cnd +o Lnckckwa}2 -TPID* 13T9G-aG of . <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Numbe <br /> l` <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: X /PV A M P L 1112 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />