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Waste Tire S y & Inspection Report Inspection Report Number <br /> 61;M State CIWMB California I 1 — 1 0 8 8 1 0 0 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board — <br /> Part A- Surve <br /> BLUE OR BLACK INK PEN: <br /> _ _ -- , <br /> Business Profile��, ..�. ,.E w; _ _. .� !Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I , I I a ) ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Ca h 7O G U!'n. COU-h <br /> `I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> y <br /> Business or Facility Name Inspected By Inspector <br /> 9 <br /> Physical Address F CAU a n /�u'4'a Truck R t?'_• r�I _ i <br /> ��� � '�� KrlSt► an Lt t.CGS <br /> �. <br /> Street Inspection Date <br /> l._ �Gh CA 95320 I _.n._ AM AM <br /> Business Re <br /> CQ <br /> .City _ State ZIP Code <br /> Time In Time Out <br /> Rep Title O PM O PM <br /> •� 111__- 111 <br /> Tim lL_GcrtercO Mc r• <br /> Operational Status 'fire Type, .' Business Role Storage Type <br /> (Fill one only) (F!11all'that apply)1 (Fill all that apply) (Fill all that apply)' <br /> Active it, <br /> t Passenger ® Generator Q Outdoor <br /> {O Q Closed Q Altered <br /> Latitude Hauler Indoor <br /> GPSJ Q Q <br /> �D Q Inactive Q.Truek , <br /> Longitude Planned RQ End-Use Q containerQ QOT <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 1 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 In Compliance - No Violations <br /> 01 O Other: <br /> Comments yp h <br /> G�i` <br /> - i1 Q. 1�(►s���'_I�YI L�-'C�D�CYYVLa TY1tS C�G\E. � OI'OWlhq 4.J�S Y1Uled <br /> FGC� tS 4 lwj \/cAuyyt AC'liQy-cA 0 01 W�+ � 1reS. t3St Q'� �.tl►^Q_ <br /> e <br /> pia tett or .IebIcle_-- �tuever ��1h�rn_-uag -i-►r rr l e bel��.n cl <br /> Inspection Form Include`" <br /> Comments Included ®, <br /> Business R2A Signature Phone Number Spector's Signatur Phone Number <br /> / _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ,� �/ F A o�d'� r�. I� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />