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vVaste Tire Su y & lnspectiOn .Repgr `Inspection Report Number '■ <br /> oa..... ��WMB1i81(New 04/04) Survey Form - Page 1 1-1- 10-8817"' } <br /> _- <br /> California Integrated Waste Management Board <br /> Part A-.Survey _ BLUE OR BLACK INK PEN <br /> $u`siness Profile ' Inspection Details <br /> TPID'- ;� + 5 _ Q Inspection Type (Fill one) <br /> Site Suffix: 4 m '® Routine Q:Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5�n ?U UQ U�Y1 C U U(11" O CHP Q CIWMB Q Complaint---Q Educational Visit Q Other ' <br /> Business or Facility Name Inspected By Inspector ' <br /> W . oot CTs ` Stockton - I 3q - I d I <br /> Physical Addre s <br /> � �(1 ,Gr LU CRS I <br /> I L10`I 5 N W' cox R d . <br /> Street <br /> Inspection Date O Q <br /> S-fi-o ckto n GA 9 5215 I <br /> City Statd: ZIP Code Time In Time Out <br /> Business Rep Title OAM mm O AM <br /> EE • m0PM [T-1 : <br /> W 0PM <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) - ISI 1 d <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> Q Closed ® Altered <br /> GPS Latitude m • Q Hauler'" Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude – Q Planned ® OTR ® End-Use ® Container <br /> ------ <br /> Business Type (Fill all that apply) <br /> ® 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 I I <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 O Q Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 –Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years v <br /> Q. O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB .Enforcement <br /> O O 1(4 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities .......... <br /> OO 14 CCR§18462-Manifest System Requirements for-Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O O Other: <br /> Comments i � T �or fhk "'r'�IS C3�C C'-9 –t t O k 111 <br /> 0 U`1'12,—. 1V15 '�g Cl_ _ W a—i�Jg,... � <br /> t rtL2r A h ra - r v (i Yn a+£1 Y�- ?�J 0 LASW <br /> -'f h I s _� (.it t_V'4 15 p � A a 1 a_�e n e-kwor.k <br /> _cam r1�Ed _ +1,(R hGH, Y-s _7by- &Q_l2_r_ <br /> Inspection Form Included: _ <br /> .( (= �-'- _...G�.�!, -- - 4a. <br /> y68 3.17�1 <br /> Comments Included: - - <br /> _ ;Business Re 's Signature Phone Number pectorIs Signtu Phone Number <br /> INSTRUCTIONS:ON BACK Correct: Incorrect. L ) 62081 <br /> _ • � [ � <br /> aWhite Copy:CIWMB. Yellow Copy:Operator Pink Copy:LEA ■ <br />