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0 Waste Tire Sulky & Inspection Repor ,, Inspection Report Number <br /> State B 81(New T i — /y Cl /, q <br /> CaliforniaCIWMB 181(teManag) Survey Form - Page 1 li 1 I0 VX 8 4 <br /> fornia Integrated Waste Management Board <br /> 08 <br /> 'art A- SurveyBLUE OR BLACK INK PEN <br /> - p - <br /> Business Profile Inspection Details <br /> - <br /> Site Suffix: ( I 1 8 - Q Inspection Type (Fill one) <br /> Site i I "I 9 �O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier. �o_� Toa q U 1 n Cow)tl <br /> 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> McCoy TYuck Tire ServIcue. , 3` g I _ ! p , <br /> Physics Address I Krt t)an L t x <br /> 10850 s. Harlan Rd . <br /> Sheet <br /> Inspection Date � � Q � � � � `� i <br /> i_ �re.nch Camp GA 85231 <br /> State ZIP Code Time In Time Out <br /> Business Rep Title j 0 AM o AM <br /> O 1 0 PM _010 QPM <br /> u e a d.O td�i Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> v <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> r3uslness'fype (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 <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M m <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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments V-aLA--%yW_ `Y,SPR_C_+�on PILAOrrV. -+V,tP rinit a -4v- �D l o w,tnc� wa s <br /> too�tA : Agvc»c. 9Z Wasm -k-ife5 s+oY�ed ►n a LGnAa,ner 4 ou+doors . <br /> Fc,c_ikik� has been ta5►n9 -�-r}-C IAYe 2ec c,1, n9 -�or waste. -tire riryy 1 <br /> b u} has rec.eyyM t, used Goldin - F r <br /> ndwt� -fro remove wa3teR101! 111M I <br /> �}r� <br /> � � ., <br /> Inspection Form Included. <br /> \ <br /> Comments Included: 0 - - -- <br /> Business Rep's Signature Phone Number In or"s Signature/"-,/- Phone Nus bat <br /> N/0 INSTRUCTIONS ON BACK Correct:* Incorrect: 'X N/' A IV.i P I- 62081 i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />