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Waste Tire SuAy & Inspection Report Inspection Report Number <br /> State B California Il - 1088013 <br /> Cgrated 1stNew Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection DetailsMEMO I <br /> - <br /> -- -- — – <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I { - % Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Y) 70Q q uin Cot_!Y)�U I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address – <br /> 2ngd Av <br /> Street <br /> Inspection Date <br /> ►:\Porgy CA 9s�6( , <br /> khl State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> ' <br /> SEQPM 0 PM <br /> S <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPSLatitude I I I ,I I 0 Closed 0 Altered 0 Hauler O <br /> Indoor <br /> i * Inactive 0 TruckN� v <br /> v j <br /> � rr <br /> Longitude – I 0 Planned 0 OTR /A 0 End-Use 0 Container <br /> Business Type (Fill all that appy)—w—' Aii� -A <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 ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 �tn2. 1`(1`��2C_tI0y) ���CiTrrW.a <br /> (�.Cit � o a lel fl r �.•I i <br /> V \CNC6 '. �CkC1�1+, ot c e_Y—, cxke gar Jo re- :r'ASAe - Ifc_ r,r-I- )fie - f�1� <br /> 1-�e. C. H .Cotj — kf-,p rt't 1L) ;,ue�1 <br /> A'\ fires tr � 1 a� <br /> Inspection Form Included: 0 <br /> Comments Included:® _ r k ! r, 178 <br /> Business Rep's Signature Phone Number I/ectolrSignature7 Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X A�, V F, X A MI P I L I E 11 2131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />