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Waste Tire SL <br /> & Inspection Repor`.� Inspection Report Number <br /> 4yi&:�Si; State of CaliforniaCWMB <br /> ,81 tew 04104) <br /> California IntgratdWaseManagementBoard Survey Form - Page 1 T 1 - 1088298 0onJo <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br />} TPID- �i o ZI O _ I I Inspection Type (Fill one) <br /> Site Suffix: (P Routine Q Re-inspection O Referral O Observation <br /> LocalC San �`�Q u n C©U{��j If Referral,choose referral type(Fill one) <br /> Identifier: J 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N10+orc ude Serv►c e _ o <br /> Physical Address �' <br /> K vsof Luce <br /> ke-tf ke_m CIn <br /> Sheet Inspection Date 011 -2Z � 0 � 8 <br /> I (....odi CA 952Y0 I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title5 ' AM O AM <br /> QPM O 71' 1 QPM <br /> ,S.I I sr-4- E(6er-1-oT-i o umer <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole%PT�) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'Wy <br /> ®Active Q Passenger 0 Generator ( Outdoor <br /> GPS Latitude Q Closed Q Altered O Hauler O <br /> Indoor <br /> u Q Inactive O Truck <br /> Longitude - , I t _L O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply <br /> Q New Tire Dealer ry Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection O Crumb Rubber LL <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other HQI0r-C-Qke /ATV <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DatemMIri'm <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O 0 Other: § <br /> Comments RoU_.% rUL___1n�- +%on pz4or reed dU+e 4 16 Q10WI n Q VJCkS <br /> 4pr�( _ 190_�aas�e�used tees 'orad on-a&e. Fsj� ,seS Ttre <br /> Howler 4 Re lc,> c_Vers , xnc . - or wosA-e /used +►rP. rerY+ova) . c`Ci <br /> May)&s[f> viewed . ,pa v io\(a+wn5 nr are-a oncern . <br /> Inspection Form Included: . <br /> (209 <br /> Comments Included: WEWsin,s, <br /> /bb Rep's Signatu Phone Number Ins ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: Xjl�, ;E X I R M I P I L I E I 112131 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />