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Waste Tore <br /> Inspection Report Number <br /> State of California Sy & Ins eetion Re <br /> ore <br /> CIWMB 181(New Survey Form - Page 1 11 . - 1088233 <br /> California Integrated Wastt Manage <br /> Waste Management Board <br /> art A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f Q I <br /> Site Suffix: �t Inspection Type (Fill one) <br /> ' I_� _-1 I v� 1 I <br /> Q Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local �S��n o coq ui nu 1.1 1 If Referral,choose referral type(Fill one) <br /> Identifier: o n t <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> RCkdiq+Or S2irV 1Ce <br /> Physical Address <br /> I. R do l b�er-�._._-Aye. — - <br /> t^ <br /> Streetl _ �,� <br /> T <br /> CA Y2 1� Inspection Date Q F2T- �"] L ? <br /> State _ ZIP Gods & _Time In _ Time Out <br /> Business Rep Title O AM O AM <br /> J + _IQPM QPM <br /> i eclru EnLA�+s G -- <br /> INI''/ "t' ,t ,, .Y <br /> Operational <br /> only)Status TirFileall ype aPPIY) Business Role Storage Type <br /> one (Fill all that apply) (Fill all that apply)' <br /> Active QPassenger QGenerator <br /> Q Outdoor <br /> IQ Closed Q Altered <br /> GPS Latitude 9 � ! Q Hauler Q Indoor <br /> 7_7j p--J ._.(C Q_Inactive Q Truck <br /> Longitude - .{ �^—` Q Planned f Q OTR Q End Use Q Container <br /> Susiness`Type (Fill all that apply) _ - <br /> _ ....w <br /> New Tire Dealer G 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 Hauler Q Agricul —- Wider- Q Other l <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <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 mm m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB f I I <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 ® 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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> fl In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ( out �n � o neer c��rn¢d tip , c1n+�eIU I1s-wInc Wa� naied ". <br /> F�e\ �1_a�_ _�roX. 350 w�_�e .+ly-a <�t�r mac lti� <br /> r e A1-er a,. e fire Geiser CAA70 r Tire; are <br /> �c 1 tri " r,-,Artoi.1S l0c.CV�\_Gn 14)T_01, G,Y) Tocl <br /> U iv.v N1✓y fy�e, b rn✓b.. ri,.n" i., ,. r .... .. -. � __ �__--_._-- <br /> Inspection Form Included: Q <br /> Comments Included: _ <br /> Business Rep's SignaturePhone Number spector'sSignat�tr Phone Number <br /> _ --_ - <br /> _ . <br /> ® INSTRUCTIONS ON BACK Correct:® Incorrect: X E X: A. MIP; t_'E i _,_L' 2_ _L31 <br /> 62081 <br /> , <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />