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092100402 ?8 <br /> 'tees <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> aaaL9a <br /> Cgrated 1(New ni ge) .Survey Form - Page 1 Il - 1088423 <br /> Catlfomla Integrated Waste Management Board <br /> Sart A- Survev" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ^� Inspection Type (Fill one) <br /> Site Suffix: I , I D l J I v5 l I O I ' I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local II If Referral,choose referral type(Fill one) <br /> Identifier: L��r� (tiu, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L <br /> ' r.r. Trucker -&c, . 13 I R - I o l <br /> Physical Address .11 <br /> 1 010 L�o ► s �� I <br /> Street <br /> 9��5I Insection Date <br /> O 19 <br /> ck �n 1016 <br /> City <br /> State ZlP Code Time In Time Out <br /> Business Rep �f,� Title/ -.}. I I � I . I I O (O AM I l I . I O AM <br /> SOK fl- <br /> - - PM <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 /> -Tire-Count(Whole/PTE) <br /> ®Active Q Passenger ® Generator- ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - i ' I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair (a Trucking Fleet Q Government • Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A HAl1LING AND MAh�rtkrZcS:IJIREMENTtS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § ,�,�� Cn 1 �,{ J <br /> Comments � `� S kqat-ls -7q111 S«f7L11JjV1JP1'0 <br /> v <br /> fits�►�f�o_f an�.o-n <br /> _ ,� <br /> v- Cead �r✓ic� � di.srnos4.' ("Y-L <br /> -firms V�tdtd. -FacitlJ nio-c, s-�vre &L -/-o 5-do Lva_sie Fres, <br /> 11/d viol adz o-�..s no�eo_( • _� _ <br /> Inspection Form Included: Q"Bsin,,sR,.'s <br /> Comments Included: Qnatur ,_ Phone Number Inspectors Sign t re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C7ecPneorrect: X A M4 P :L E 1 2 3White CoYellow Copy:Operator Pink Copy:LEA <br />