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-%y & Inspection Repor, Inspection Report Number <br /> NWaste Tire SL. <br /> � State of California <br /> CIWMB 181 <br /> eIl - 1088289 <br /> California Int grat dWas Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- �t Inspection Type (Fill one) <br /> Site Suffix: I Z ' V - U <br /> 0 Routine 0 Re-inspection Referral Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Son, TOGS�4)n C vu r,�'y <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Crev��f7y�A i -- <br /> Physical Address ( 0 I <br /> _t 1 I Kv- �StiGn LucgS <br /> "�on Rd � i <br /> S6'c:et <br /> Inspection Date <br /> Tri GA 953Oy , v <br /> State ZIP Code Time In Time Out <br /> Business Rep Title /lAM 0 AM <br /> VAP-06F I nn� Q ' , V Q PM O QPM <br /> nor - --- <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 /> im ® Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude mFT 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - I 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 0 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. § ( 1 <br /> Comments n .} ,,n, 1� �L j Cz►'1 iy2 t n�C� '�1`:; C�RT2. �_� � �1 O � <br /> _r,0- d . No wa_JE or +_.ed *Aces -kLrC_d_ on--'t�-e.- -7e��� � u e Wlk.: On <br /> rY, service Uca:te flu-eA + r_e ,r'emovQ1 . <br /> VAckyP_ been ► 4 weye availableor view <br /> p : O <br /> Comments Included _ <br /> Inspection Form Included: l <br /> I <br /> Business Rep's Signature Phone Number I pector's Signature( Phone Nu__ <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: X E X A j 'i (r g 1 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />