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Waste Tire SW & Inspection Repospection Report Number <br /> NEW` State of California ■ <br /> sa Survey Form - Page 1 I1 - 1088213 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey - BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - - _ . <br /> TSite Suff PID- c �� Inspection Type (Fill one) <br /> ix: 3 ` J � 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -}-- 1 If Referral,choose referral type(Fill one) <br /> Identifier: S an J o Q q U1 Yl C 0, t'1 rl f <br /> ., Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> Physical Address _ T 3 <br /> --� .� ► �}►can_. LUGS <br /> 1. -7 5 2 'F_ . -M-_a�n St. <br /> i Ins ection Date <br /> CA g_2'�dZ� <br /> 1 o18 <br /> CityState ZIF lode Time In Time Out <br /> Business Rep Title <br /> O AM O AM ! <br /> —..__....- <br /> FT-_ O PM Q PM <br /> m Operational Status Tire Type Business Role Storage Type <br /> i <br /> Tire Count(Whole/PT�j v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> 10 <br /> ® Active Q Passenger Q Generator Q Outdoor , <br /> j - -- <br /> I - M ISIO Q Closed Q Altered <br /> GPS Latitude <br /> Q Hauler Q Indoor <br /> [[ Q Inactive Q Truck d� <br /> Longitude - f Q End-Use Q Container <br /> —. 1 Q Planned Q OTR <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 § Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 ® In Compliance - No Violations <br /> O i Q Other: <br /> Comments ROu�I <br /> Yl�\ 1_ ( # �l <br /> RQ PRC 1 1 C,Y-\ Cert Ur mCc, i� Q C � -- wlnq-�_ <br /> r drecl �'Ad r_Lre re 4n—s��-e ala - ce �v ice ��cwrs Ort- �_I+e <br /> _all jQA),QeJ ctre- _erv_Icec -C e�)t1 or ��� Tire Ca . Nloy►ala+l0ns <br /> yT, <br /> Inspection Form Included: Q' `'f f'C..;'a•t <br /> Comments included. Q, __. . - { i <br /> Business Rep's Signature PhoneNumber ;sp�eCttor's Signature Phone Number <br /> be - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,A�,, V ;E ';A 10ip), 1^�[ , g c 3 62081 <br /> aWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />