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■ Waste Tire Sui&y $II. Inspection Reportslnspection Report Number <br /> nui State California Survey Form - Page 1 11 - 1088132 <br /> CIWMBB 181(New ry - <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 11ns`pection Details <br /> I TPID- I , Inspection Type (Fill one) <br /> Site Suffix: � <br /> �Q Q '7 Q (9Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C CA Y) To Ck G 1 I Il rl Co U ni <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> -T"[ U - <br /> Inspected By Inspector <br /> To n,� �k n <br /> _. __ l 3 _ ! <br /> Physical Address Ll 101 <br /> Street <br /> Inspection Date [�iJl <br /> Business Rep �� Mate 21F Code Out <br /> J � In Time <br /> � � Time <br /> Title Q AM i M <br /> l <br /> ' PM � ' _ 0 PM <br /> LC►_r c _._..___. 1.. <br /> Tr rt V're ► Ac <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill one only) apply) ( apply) ( p,(Fill all that a I Fill all a I Fill all that Y)a of <br /> k i i ppb T+r pelt 4d� �rn <br /> ® ACtIVe Q Passenger . Q Generator QOIItdGIOr <br /> Latitude l Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 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 g1Q(lection 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 FHAULING AND MANIFEST REQUIREMENTS <br /> Q ® PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> IQ 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 <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 ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I <br /> - .. - - — -- <br /> Q 0 14 CCR§18460.2-Manifest S_ystem Requirements for Registered Waste Tire HauY'er5. Q Referred/CIWMB Enforcement <br /> 14 CCR <br /> 18461 -Manifest <br /> stem <br /> uirements for, aste Tire En -Use <br /> es <br /> OO 14 CCR§18462-Manifest System Requirements for,T re Dealers ordWaste Tire(Generators <br /> Q 0 § Y q <br /> Q IQ Other: § (j) In Compliance - No Violations <br /> Comments <br /> out�rtie ►nom t i�c,� r� r r_ _ h�+�—du-�e --the - I n _WG Ac <br /> FC, ran; ar ec - t0 -an o� �r�,ck �� �: in ve)0 cle <br /> c Y�c_ <br /> °IQd I o (�l0C&-n - FJt_a- Yf-0 ia.cf-':,_� r-EC_LJV_EE CA _I�orn C 1>✓JN <br /> Lklrt'('n\Z^C( h/l ' ri( I n rr1! _i_() A1(•1lA1 r`r / nY C i Y C- cC — \ i <br /> Inspection Form Included: Q " to <br /> Comments Included: Q _ ✓ <br /> Business Rep's Signature Phone_ Number Itrspector's Signature Phone Num, <br /> INSTRUCTIONS ON BACK Correct: Incorrect. I wAe, t 62081 <br /> a.A Rile I_IER � is ���� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />