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Waste Tire Su. ly & Inspection Repore <br /> Ilnspection Report Number <br /> G 71W State of California <br /> 6I 1 - 1088403 <br /> California Int grat dfWastJe Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE_ OR BLACK INK PEN <br /> Business Profile 1*Inspection Details <br /> Site - I LOS <br /> Inspection Type (Fill one) <br /> Site Suffix: (O FSj (� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local inn 'TOAq u <br /> wo C Un+ If Referral,choose referral type(Fill one) <br /> Identifier: y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> rte. M o+"r� =n C <br /> Physical Address <br /> 10 L U beC-�-rnan V-A <br /> Street <br /> Inspection Date <br /> Lo dk CA 95zya l <br /> State ZIP Code Time In Time Out <br /> Business Rep Title I 0 AM , T O AM <br /> ' QPM = ' 0 PM <br /> L_arr Zenker Ports r1 r. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> m . O g Closed 0 Altered <br /> GPS Latitude � � 0 Hauler 0 Indoor <br /> F—T-7-71 0 0 Inactive 0 Truck / f�/X <br /> Longitude - 0 Planned 0 OTR N 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® 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 /> 0 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 /> 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 I 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 O In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments -I q n.Q d l,C_ T f- 1 C) �7 E vtl ek e M cAoT- <br /> hta. been � Znc <br /> 103565` —U1 6ewe�ce To�o1'a (TPip 4 1315016 - 0) . Th�:v miry ber Traci <br /> prey tou5ly keen 66-_e ) UZ o808 Lj� VJT MS \naWw business cVe . <br /> `2ecomnnd to cto � TFC`;_ 4"=_ 10350y_ Ct� . <br /> Inspection Form Included II _ 1 7-- <br /> Comments Included. 0 - <br /> 4s/11 l � u ✓ vr.M 76 <br /> - - - <br /> Bn�s Rep's' Si ature Phone Number spector's Signatur Phone Number <br /> 62081-- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � A A P IT E - 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />