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Waste Tire SL_ iey & Inspection RepoA Inspection Report Number <br /> State B California I 1 - 1088201 <br /> Cgrated 1(tNew <br /> Manag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> o -� ' I I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local { If Referral,choose referral type(Fill one) <br /> Identifier: -�'n _-t^ocac��',h C ou nfy 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ,,u�:►d,� �- Tri►ler Ke ��,tr I _ _ <br /> Physical Address J C) I` I l f I I Kr I•tet I c,n L_u c G� <br /> L b-4 l ti L a n.4 �-re.e k(A i <br /> St,Eet � <br /> Inspection Date U 81 C) 18 I I (P, <br /> r-CA urs CA gr_3ZU <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> A 0 PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> rTireount (Whole/PT (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 /> u 0 Closed 0 Altered <br /> GPS Latitude I ,I I 0 Hauler 0 Indoor <br /> ® Inactive 0 Truck NA 11;/A. <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 <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 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 <br /> f�C�� tri. eco✓�QG.}ICT�t �r ofrv�u c_� -��t�- (tcf�e Y Tf'te �cdlnra.1_tn j w G l 1'i(1f(7 <br /> 1=c�c_►�►�1 fir, vo etc,h C-1r 41e Hca .fe +Ire, . _Zr �� ►_.tom �c I���• � <br /> ll",J\L`,t 0 - ttrc- -+r,rca oY\ �ceml_C3 -4-� 4W lctncl M In 9r ,cr+t,file- o� 4'1 ar <br /> Rec()mftLC0,C1 +r� If)nC-ttV4e_ -TFIP ISIgS�' 1 —Cj1 . <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - r =_ '- <br /> Busmess Rep's Signature Phone Number Insp s Signat <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X :Ak \/ a E'X;A MIP L i E 1 11 21_�j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> �1 ; <br />