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MWaste Tire S _ & Inspection Repo"nspection Report Number <br /> �'.2n State of California ■ <br /> CIWMB 181( enaSurvey Form - Page 1 I 1 - 1088409 <br /> California Integrated WasttMa <br /> Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Site - InsRoutneT Re-inspection Referral Obse <br /> 0 � P YPe (Fill one <br /> Site Suffix: O O 0 <br /> - Observation � 'I <br /> Sin 3oc� ..u - <br /> Local ,� If Referral,choose referral type(Fill one) <br /> Identifier: 9 In �+ou1� <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p Y Inspector <br /> Physical Address 1 - t Q <br /> Kr�stlan Lues <br /> Street -9 <br /> Inspection Date <br /> L 1_ca-kh rop 9155-30_i <br /> 530_..1 <br /> Sf�{e �/p Code Time In Time Out <br /> 0 AM 0 AM <br /> Business Re - <br /> f _ O PM ' p PM <br /> I n o' cky G I_IAC. _. I t—_ _.._ _. _ , <br /> P Title <br /> " - ,,. - --- <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "^i 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> � Closed 0 Altered <br /> GPS Latitude [II - E E_7L_7 <br /> 0 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck o <br /> I <br /> Longitude - I Q Planned0 OTR Q 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 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 <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> -- 0 Notice Of Violation 0 Extension <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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 11:1 / LII [I] <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) y <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 /> 14 CCR <br /> 18462- <br /> OO Other: § y q _ in Compliance No _Violations <br /> 0 O § - - <br /> Manifest stem Requirements for Tire Dealers or Waste Tire Generators <br /> Comments " ive 142.S-Z9--01 <br /> Qre rio �n�l_�er <br /> U t�L-ted Gt s-c�2 . M T Food Service. TFIDI�,5Z$9Z- <br /> n <br /> '9 2com,(yLento c.1 o t -1L1zs-n q- Gt <br /> 1051 <br /> t <br /> on, orm Included: O� <br /> InspeComments Included. Q <br /> �Business Rep's Signature Phone Number In a is Signature Phone Number <br /> -. - - <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: , <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />