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r <br /> _ Waste Tire SLy & Inspection® Re o Inspection Report Number State of California p ■ <br /> _or CIWMB1819(New(14/04) Survey Form - Page 1 11 - 1088287 <br /> California Integrated Waste Management Board <br /> Part A- Su rve BLUE OR BLACK INK PEN <br /> -_ <br /> '$usiness Profile„ _` Inspection Details <br /> TPID- r- Inspection Type (Fill one) <br /> Site Suffix .� _ –� �� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - f"0 To o g w n C o'_n <br /> tl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> rel <br /> ke T'r\)ck 1. ec�Iin I =0 <br /> ... <br /> 0 I <br /> Physical Address c <br /> ��C1_�-jG(9 LtaCrr� 0 <br /> ,Street I <br /> Inspection Date t �_ —' –co <br /> City State Zif'Cade Time In _ Time Out <br /> Business Rep Title Q AM0 AM <br /> .2 <br /> QPM � � �'. QPM ' <br /> DO U <br /> � ` <br /> Car r <br /> OperatinlIIIStatus Tire TyBlsmeole Storage <br /> Tae <br /> (Fone only) ( that apply) ( lthat apply) ( alapply) <br /> Tire Count(Whole/PTE) <br /> ® Active 0 Passenger ! q Generator 0 Outdoor ; <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> "Q 0 Inactive 0 Truck <br /> Longitude – --�� 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> IQ 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension ' <br /> 0 ! 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> n In Compliance - No Violations <br /> 0 0 Other: § -------- - <br /> Comments <br /> ---�a�t-41ne lv,Snec lQr� r�vrmed 44-11_. cicr�e. 4oI)iow\nC, iAo !i ro+Cr) <br /> LAS.-40'0 WCkje, _+_\Yc _ <br /> ��rf,oyaL. -T\rem r-ernCgt6 �rom �t�e_. (, ffoy. 2- +irn_e_ `,y` �c .-- CTL_. <br /> tA� <br /> Inspection For Included. 0. <br /> Comments Included. J r <br /> Bu ess f ep's Signature Phone Number liispe for"s Signa_Lure ' 'f Phone Number <br /> INSTRUCTIONS ON BACK- Correct: Incorrect: X lipi x; A 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />