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Waste Tire SuSby & Inspection Repors Inspection Report Number <br />eoa. <br />State of California <br />Cgrated Waste <br />Survey Form - Page 1 1 1 1 0 7 9 1 9 9 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: t 3 Q j 0 � 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier. ��'�i �TOGC� U f GZ r� oA'C1w1 <br />Business or Facility Name J <br />Physical Adre <br />ldagn Um —V( UGk1 (19 <br />Soso <br />L(xi-k)rO1F CA T51'�'�10 <br />Business Rep Title <br />Tim C.\2rAg. * <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />t•J <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />3 Ct- ` <br />B - <br />Time Out <br />K(isf� G� <br />Luras <br />. <br />O PM <br />REQUIREMENTS <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Operational Status <br />Inspection Date <br />0 <br />3 <br />� <br />0 8 <br />Time In <br />B - <br />Time Out <br />ENFORCEMENT STATUS <br />0 AM <br />. <br />O PM <br />REQUIREMENTS <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Operational Status <br />Tire Type <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />0 Passenger <br />0 Generator <br />0 Closed <br />0 Altered <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Hauler <br />0 Inactive <br />0 Truck <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />0 Planned <br />0 OTR <br />0 End -Use <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />0 AM <br />0 PM <br />Storage Type <br />(Fill all that apply) <br />0 Outdoor <br />0 Indoor <br />0 Container <br />Tire Derived Fuel <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />HAULING AND MANIFEST <br />ENFORCEMENT STATUS <br />1 <br />�q <br />REQUIREMENTS <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 Notice Of Violation 0 Extensio <br />0 <br />0 <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />0 <br />0 <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT <br />J <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />- - ----- ---- <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred I CIWMB Enforcement <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />00 <br />14 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />CCR § Y q <br />In compliance - No Violations. • L <br />O <br />O <br />O § <br />Comments � t <br />f�C� eC I%or\ ruzIC of M rA -� n� h dock A "t &1kdc. m4 .,)Os npTe( _ <br />-A <br />} X+sj o5cs I Ra ScV)wa6 �or Nc sAx -ire AGTL e-in►ke- �In Coge <br />Inayf\ (e awwd wNe e- agnAoLbLe &C Jievaira on CVeGLlkf- No V iJ aAi a nS of <br />sA�C3� conc�-,rn OAP- - 4 alrir esus tube _ t a�_n _- m. <br />Inspection Form Included: U <br />Comments Included: <br />(4/- <br />_ BusinessITSignature Phone Number <br />INSTRUCTIONS ON BACK correct:* Incorrect: <br />White Copy: CIWMB Yellow Copy: Operator <br />IVIA�,MIPILIE! 1112131 <br />Pink Copy: LEA <br />(2o9) <br />Lib�- 3178 <br />Phone Number <br />62081 <br />