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Waste Tire S&ey & Inspection Re of Inspection Report Number <br /> ■, x6r.a:�a State of California p _.-_ -. .. .. ■ <br /> �r CIWMB 181(New04104) Survey Form Page 1 I 1 - 1088284 <br /> California Integrated Waste Management Board Y J <br /> PPart A- Survey " BLUE OR BLACK INK PEN <br /> , .,, <br /> business Proftl+ " Inspection Details <br /> � a <br /> Type (Fill one) <br /> Inspection Site - T 4 <br /> TP <br /> _ ('}_jl - 'lI_�'} �I(( "' IIII <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: F CAY) 7b C{q+ t 1 Y') CO on �t.I <br /> ,/ _ Q CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> all ar r) CAS+C �T►re 1�1�anc; e.men C� _ <br /> Physical Address 1 I 0 �� I, i cin LtA S <br /> w- 7 <br /> Street <br /> Inspection Date <br /> T5as' <br /> /rGc'► CA 95376 <br /> City j - _..._-_. State ZIP Code'I Time In _ Time ut <br /> Business Rep Title _ f ® AM Q AM <br /> . <br /> PM PM <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 /> i 3 <br /> ® Active Q Passenger Q Generator Q Outdoor I <br /> 0 Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O <br /> O Inactive Truck <br /> -- <br /> ,o <br /> Longitude - Q Planned Q OTR O 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q 'her <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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of-fires <br /> Q O 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 111 <br /> / m Ell <br /> Q 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § <br /> Comments t I_ j Q G l l rAppu}I rl a5 <br /> rox(c� . IAII 5 �, a,,Ve Au ed - Ire C�-`-� r-A C r,- �rc .-FGc 0 Li u_ es <br />} <br /> dam--n 7 %fes - Cir �lto_.te- ill re r"en',Gva\ -'Crs r„ Ae . Tl rc_� orC <br /> 7lres Zf?C__ S-CL <br /> Inspection Form Incl ed-' O,', <br /> d O r <br /> r t <br /> Comments Included ,,�- --- - _ ---- <br /> O Business Rep' Sign ire Phone Number I pector`sTgn"IG, t rp' ";)ajj` ,r <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I 7 �.._.. 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />