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Inspection Report Number <br /> ® Waste Tire Suft., & Inspection Repo _ , p p � <br /> w�m$ P State of California I 1 - 1088019 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board .. <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> !ns ect[on Details <br /> W.. - <br /> Business Profile , P <br /> T' <br /> TPID- Inspection Type (Fill one) <br /> , <br /> Site Suffix: 1Li0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> —r- <br /> Identifier: SOn J OQ9U in Cours} Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> — —E <br /> Business or Facility Name Inspected By Inspector <br /> _ <br /> Physical Address 3 L x1 tin Lucas i <br /> 7ti 123 _s . ht ct�n S-1-.._._�_ _-- —._ —� k –- r6T& <br /> Inspection Date -1 <br /> ---_5. - 3a <br /> 9.._ State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 PM � _ O PM <br /> apply) Storage Type <br /> Operational Status Tire <br /> Bu ole <br /> (FI oneonly) a apply) ( all that app y) (Fill all that apply) <br /> QActive Q Passenger Q Generator Q Outdoor <br /> - - O ® Closed Q Altered <br /> GPS LatitudeFTI Q Hauler Q Indoor <br /> io Q Inactive Q Truck <br /> Longitude <br /> Q End-Use Q ContainerQ Planned Q OTR <br /> Buri less`;ype (Fill rail that amply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> -- - - -- - - - - - - <br /> Inspection of Waste Tirr Generator, Hauler Dealer, ator, and End-Use Facility ENFORCEMENT STATUS <br /> Part 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days Q l 9 - - <br /> - I <br /> 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 /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q - ® In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> e4 'e_(W m n-Cr-XA A0 c 1 ose Ca <br /> � <br /> inspection Form Included: Q d <br /> ConnnlesnEs hiciudoci: Q _ - <br /> Business Rep's Signature Phone Number Ins6ector s Signature' ' Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: •t ;. �;a L' <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />