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Waste Tire SL my & Inspection Repor Inspection Report Number <br /> State of California <br /> CWMB grated Waste <br /> eManage) Survey Form - Page 1 18 - 1 0 7 3 4 3 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- , Inspection Type (Fill one) <br /> ISite Suffix: "1 O 0 Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `Jan To Aq u m GOUT-)+j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> bCLnc, Go'rp . G _ v <br /> Physical Address l 0 ' tom(l5tIgYl LLtcco <br /> 0550 -_J:Y') au5-hrtC►1 DC, <br /> Inspection Date 0 3 o 8 <br /> S+0ck'_ c n GA q�52oG <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> ' QPM QPM <br /> X02 3+ Ibq® {-4.R. Mana er - - <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 01' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> lb Active O Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor 7 <br /> O Q Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber C�h�ls <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder A Other �Gh1G�e MA11��C1U1�211 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> 0 Notice Of Violation 0 Ex e <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT)' <br /> ----- -- --- <br /> 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> . --- --- -- <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Com Bance No.;Violatior►s , <br /> Q Other: § <br /> Comments <br /> nx -�'hts �4� e. � -Une - Ikow;ny-IQs na�-e� <br /> F�,��1►�-�t�5es__ t�a�e �or �'t����- ��re se�U;ce � �il�\sar1�}siy �"�r'P Com, <br /> C�x)sa�-e. -tc r(-�, hs�u t r S�.r��c e-S - '--�► <br /> Inspection Form Included: 0 a� IQ ►O _ C2Ag <br /> Comments Included: _ '31 ZPS <br /> Bu ines Rep's Signature Phone Number In ector's Signal6rV Phone Number <br /> 64 <br /> INSTRUCTIONS ON BACK l P 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />