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Waste Tire Sul & Inspection Repor' nspection Report Number <br /> 1 Ix� �/9g y^� <br /> GO DI State CIWMB California I 1 — 10 8 8 •'4' O V <br /> California Integrat d Was181 te Management Board ew 04/04) Survey Form Page <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile' !Inspection Details <br />} TPID- Inspection�- Inspection Type (Fill one) <br /> Site Suffix: I LZ 8 � 2- � <br /> S 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local~ Wl If Referral,choose referral type(Fill one) <br /> Identifier: �S _3G A g U I n CCU rr� <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> M 4- T F30Cd <br /> - <br /> Physical Address —�- 3 5 - Ll <br /> o <br /> -- — I. is I n Luc4s� <br /> I I q(31 S I4gr )an ?J - <br /> Street <br /> Inspection Date Q. <br /> Loki GA 9533 .j <br /> State 2%F'Code Time In Time Out <br /> Business Rep Title O AM Q'AM <br /> I_ <br /> �� (� • .. L " OPM PM <br /> fA C(r �\n_ _.. 0 W nfz.r --- <br /> ------ -- Operational Status Tire Type Business Role Storage Type <br /> 6 i46 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .„ @ Active 0 Passenger � Generator 0Outdoor <br /> Latitude (( ((' 0 Closed 0 Altered <br /> GPS � • � �- 0 Hauler 0 Indoor <br /> —t-- 0 0 Inactive 0 Truck <br /> Longitude - ! 0 Planned 0 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other M O T Y ci <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - _- -- - --- - <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> I <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 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 ® In Compliance - No Violations <br /> 0 0 Other: § -- <br /> Comments :jn►j la, ►h5w_r_�ton im_ Tc r ryl� C}oC`e _.--J+tk -6 l I v t !h 5 ;, a 5 _ <br /> no}ed: Ao�r ox. 66 � paste fused -�4r c� S�aYed oh-5i+e bA ou'rdoo rte, <br /> iyti ct c.ofrVQtryy- . Tbk"S Is G CLC I.SZ �lre iJus�Hess oS�ra tnG ou'k IS <br /> �4Ca '1oh has been Qne.n . or gpproX . 1 monJ7h No ,Josie/used +Ire., <br /> ..aspic d <br /> - <br /> Busirie`ss Iep s 5i+gnature Phone:Numbet I ctor's Signature- Phone Number <br /> ft <br /> 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />