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Waste Tire SL".. & Inspection Reporspection Report Number <br /> 3s8+ � State of California 11 — 1088278 <br /> CIWMB 04/04) <br /> California Int grated f W81 as eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business;Profile ` Inspection Geta Is <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: � 6 L r Routine Q Re-inspection O Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: S G r J T O Qcl w I n Co ur) Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> ----- <br /> Business or Facility Name Inspected By Inspector <br /> AkIS <br /> Physical Address - 1 I Q I / I <br /> I Kr Ist I an Lctc4 s _l I <br /> h2-o,45 ) <br /> Street �1 l <br /> Inspection Date <br /> a� ..__ � �r3ZQ_i [.1 <br /> 1 F­( <br /> City State: ZIP Code Time In Time Out <br /> Business Rep Title � AM iQ AM <br /> O PM O PM <br /> ctY(ISOrI Yl . �"� - <br /> li I_. SSP+ �.__.-_— _ �I-_ ____.-__ r_.. ___t Operational Status Tire Type Business Role Storage Type <br /> {I <br /> (Fill one only) (Fill all that apply) :(Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger j ® Generator Q Outdoor <br /> Latitude Q Closed 0 Altered <br /> GPS Q Hauler 0 Indoor <br /> -�T 0 1= =_E_ 0 Inactive 0 Truck <br /> F_ 1 '� F— Q End-Use Q Container <br /> Longitude - O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility L E O CEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 11 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> 00 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 /> 0 Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 0 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: § <br /> Comments <br /> e 0 ut I Re ,t, Q ct I J n cat.'( �a r rnerl cl n -+I _ Ca CI+C <br /> in 0+( : FGc>l►�u McCc,- ---7_r_�c�k_-_ Tt�e_ Service_ � r ilre 5�-_r- v,(e <br /> "1r_P_ rernoyG" F_uT rr,onA-, t.5 h vP �_:: n C-eN(AIylp ,)ere -kVCkActhle_ - <br /> on ue. No v0()latl 0V_, - 0r Crcv_nserf)3_ <br /> Irzs' ectf"ry Fbjri�r'!In"dlud�d: �' `� ;,, ,�„ , •,>, �; u. : >, A, .,, ^. �� ;" <br /> Comments Included: Q <br /> usiness Reps Sig at a Phone Number 1 ed or'a Signature Phone Numbed <br /> X -- -- <br /> --� 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: A M, P L e - I � <br /> MWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L <br />