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W spection Report Number <br /> Waste Tire Sua & Inspection Report : <br /> State of California <br /> Califor CIWMB 181(New nage) Survey Form - Page 1 I 1 - 1088411 <br /> California Integrated Waste Management Board <br /> P_ artA- Survey _- BLUE OR BLACK INK PEN <br /> Business Profile_ ' k inspection Details <br /> LTPID- ' �, � 7 5 u f - in Type (Fill one) <br /> Site Suffix: 7 <br /> ,• Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalC Q -t-Oq U�n Co fin} If Referral,choose referral type(Fill one) <br /> Identifier: J •J q l y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ?o ad Service 3 9 _ I O <br /> Physical Address <br /> /� i 9r,st,4n LUc4s � <br /> 33"z`7 S . Vi►y h wgN 99 I <br /> Street <br /> Fc)Inspection Date 1 I Q <br /> StoCrk-toh _CA 95Zt5 8 <br /> Crtv State ZIP Code Time In Time Out <br /> Business Rep Title O AM I O AM <br /> ' QPM QPM <br /> O w ne-r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' q ® ;; (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS �_I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - . I 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 tAob i te. Tire Sy, . J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / M / 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 I 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 n tt 1Gil <br /> ►1nC r d r� fih►s ��t-e �- thQ �Cotl o lel ng was <br /> A nProX . �l0 t t-5tc -t-vres !�5kreA ori-site. Fac-'Iliv Is c, <br /> ,nntbtte. - Xre sQrylce oDercAjj)g lnautt m <br /> jV c> . O W Rar !! 'kcx_te_b_ '�1n iWL =e1�-ti t•1 Q r- les!, 41 res io e l�6 r <br /> Inspection Form Included: Q \ (201 <br /> Comments Included: - - <br /> Busmess Rep's Signature Phone NumberI pector's Signature Phone Number <br /> 7n <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I- V I(_E X A M P j (r E! 11 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />