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Waste Tire SMy & Inspection Reposelnspection Repert Number <br /> `i57S+'a State California I 1 1088166 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection�. Inspection Type (Fill one) <br /> t Site Suffix: I I � 8� - W <br /> 1 Q Routine Q Re-inspection Q Referral @Observation <br /> Local 5 � Q U1 f-1 C cktfl T If Referral,choose referral type(Fill one) <br /> Identifier: U `J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> MIdGs � 3 _ <br /> Physical Address O Y Kr 1st ion Lu ccts j <br /> i 33 F Ke- z mcarp L—n . I - - <br /> 1 <br /> Inspection Date 0 / G 1-f / Q 8 <br /> 95Zy01 v <br /> Civ L Q��1 State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> W ' L 0 P 0 P <br /> C�.r�o t�nd�lla SVG M f. T - - <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m m m <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ccc-��► �- tin �c.�r>QrL _ r o-r-rntd thls 64-p-- i 7t6---�;Alownwcl <br /> ��'�o�a� L Gid taG��'tnh � �..IGns cin �onttru��-� #o ui� t�c, d�1lcL <br /> V„�,v, \teem r-. e<a �X rr< C oncCr(—) <br /> - <br /> Inspection Form Included Q ,�� ., / ft <br /> _ <br /> Comments Included. <br /> M :E)dsiness Rep's Signature Phone Number I pector's Signat Phone Number <br /> / <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V 3 A M P L I 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />