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Waste Tire Su <br /> ■ __-,4 y & Inspection Re ori p Inspection Report Number <br /> State of California <br /> ia CgWMBrated 1(New04104) Survey Form - Page 1 I 1 1088138 <br /> California Integrated Waste Management Board - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> - <br /> Business Profile Ing `�� <br />} TPID- ' L, r q _ U Inspection Type (Fill one) <br /> Site Suffix. -1 \O I Routine 0 Re-inspection 0 Referral 0 Observation <br /> f <br /> Local a n J I <br /> � 1 I If Referral,choose referral type(Fill,tine) <br /> Identifier: - U app U n O u s t <br /> `1 Q CHP Q CIWMB Q Compl'aint:,, Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �c�Y r-nor�� ►�/��`��r I <br /> Physical Address - —•..____. - �. LOLI ] <br /> krl:.�tlrtrlUCGS .I <br /> i <br /> Street G 25 U F_-,F_-,c_cA I.o n __. 8 x" Ute ._.. _._..._I _ <br /> �� <br /> Inspection Date i <br /> Li nd-e n C1\ 9 IsZ_;Z,G 1 Time In t� Time Out <br /> Ciro State ZIP Code � _ _ -., <br /> Business Rep Title AM Q AM <br /> Llu _i � } <br /> is G,0c GYM O PM —(` -O PM j <br /> - .. -- <br /> �G . �.� _ d G er <br /> �; ,� fit,✓�il� y� , ,,r � �,, ,. T. ,+ su;,, ori,,, , Operational Status Tire Type Business Role Storage Type <br /> s dry (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> Tire Count(WhalelPT � i <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude 10 Q Closed Q Altered <br /> GPS EEI QInactive Q Truck <br /> OHauler O <br /> Indoor <br /> Longitude - I Q Planned Q OTR O 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 V( ,le I' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FFI / M <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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 /> --- -------- <br /> ----- - <br /> O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Other: § -- -I <br /> Comments -th I SC�Ct1� t <br /> .��� note a^) <br /> rcaY)non 7Ire �Gr LJGSo *e -A\\ eUnS- :art -CC-Ct, ir✓� .. ► �_t <br /> 11c�ve bc.e►1 #c�\re-c1 mere c,vr�t�c� �1 or tri „ re ruet. IAC, - <br /> \J� erAr> r C, rnc_er0 , <br /> Inspection Form Included. Q 1� I <br /> Comments included: O <br /> Business Rep's Signature- Phone Number Ins ctor's Signature, Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: I� J A; , L E l 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator - Pink Copy:LEA <br />