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Waste Tire Say & Inspection Repo%inspection Report Number <br /> =r�. i= :. State B California I 1 - 1088031 <br /> �oj� Cgrated 1st(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I � � � � � i - [q�f <br /> Inspection Type (Fill one) <br /> Site Suffix: f @ Routine Q Re-inspection Q Referral Q Observation <br /> Local Don Tc�qu�n C� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ()nCkOson T►re 4 AtAto i I _ <br /> Physical Address q I ( Q r <br /> I ILC is-t'►an LuC4s I <br /> Z`1 O hA . H U n+e r <br /> Inspection Date , ]:0 <br /> `4oc k+or l CA 952o2- <br /> State ZIP Coy- Time In Time Out <br /> Business Rep Title � AM � 0 AM <br /> 0P 0P <br /> 'T,ryjes n,:-r) —, O w f1R.r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> ` O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> GpS Latitude <br /> . D Q Closed Q Altered <br /> � Q Hauler Q Indoor <br /> O Q Inactive d Truck i <br /> Longitude - Q Planned ® OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ® 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 /> 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 /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> § 9 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: § <br /> Comments FaLtArN . kmpeC.t.o p"ToywAd 4i:, dQm 4 Pub jollowing tNQs _f-1_o-led <br /> _I(0O W Ck used +res S3 0re-d On-5,11_ C FOC-Ali, u _F ►ctd Ila -. <br /> T\rel V1:A)0sal Aor „�a5tekraed ire removal . CTL man► estg we <br /> re�r��n e_d t�►a_ v 7 ol�t��n �r re-as aVIP Ar <br /> Inspection Form Included: <br /> p f� a <br /> Comments included: Q', � r,-�,'; + �P. 1.1_c� <br /> Business Rep's Signature Phone Number In3{Sector's Signature ' Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X Ak V � X A ,MIFF E' 1 2�3I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />