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Inspection Report Number <br /> Waste Tire Su&y & Inspection Repor <br /> A <br /> State of California <br /> �;27 CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1088121 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ;i Inspection Details <br /> TPID- I G Inspection Type (Fill one) <br /> Site Suffix: 9 �� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S n 7^oct 9 uln C Urr}4 <br /> J � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � I Tr0norfaA+on i <br /> U <br /> Physical Address <br /> -2 L9 <br /> – I I < <br /> �fl,AIctn L.uCGs <br /> 2-HIS 9 M ar ) pus a Rd. I <br /> Sheet Inspection Date U Q 8 <br /> S�-u cktan CA 95 Z_05U5 1 V t <br /> State ZIP Code Time In Time Out <br /> Business Rep Title II JOAM 0 AM <br /> t� <br /> O PM O PM <br /> TInck T Munn, er <br /> Operational Status Tire Type Business Role rStorage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS W • I I I I I Q Hauler O indoor <br /> — O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply • <br /> Q New Tire Dealer Q Auto Repair O 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 Q Other <br /> e <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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/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: §L <br /> Comments d c <br /> RU 1,.lt(T1C_- I-r�-%�c��to�� uJ rt S <br /> Cn C Qc,111� t eS Q�CdP_ 1 - Co_tcts - WIlson "G(, 71fe Co . <br /> r �0AC lic ren)OVct`� __�fc� tire. re,1r A 6jmg E-DTs Vie bee in <br /> rr�G�rtG<_ _ ``t �tI\JOAAQ_ �,I fy_e 1 ', c')fl, f2 t.,eST . No VICA(AlolnS of cxens 0 <br /> Inspection Form Included: Q <br /> Comments Included: Q – _ _ _ 7ectr4 <br /> It <br /> Business Rep's Signature Phone Number Inignature "Nu <br /> • r`, ��� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect) n V F=�� �4 Jldh F� � � I i � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />