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Waste Tire SLy & Inspection Reporinspection Report Number <br /> •i 27 <br /> Stateof <br /> 181(New <br /> I1 - 1088404 <br /> CIWMB 181(teManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLU_E OR BLACK INK_ PEN <br /> Business Profile l,y Inspection Details <br /> TPID- I I Q / - L?L Inspection Type (Fill one) <br /> Site Suffix: G Q Routine Q Re-inspection Q Referral Q Observation <br /> Local son -To q LA\h C U un S u If Referral,choose referral type(Fill one) <br /> Identifier: J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> rO <br /> Physical Address ' G I K( +„t"I con Lu c as <br /> � uZU S. F3�2ckmctn Rd . <br /> Street <br /> Inspection Date I U / F(3 -3 <br /> CA 99p29 CZE <br /> State ZIP Cod Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1L t� 0PM � ' �_ 0 P <br /> r <br /> nrr 1 Zer1 r rGC [ 1't . <br /> 0 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 /> ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . �I I Q Hauler Q Indoor <br /> _ <br /> O Q Inactive Q Truck <br /> Longitude - 71 -FF <br /> - i Q Planned C>OTR, Q End-Use- Q Container <br /> T <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 ® Car Dealer Q Collection 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <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 Q - - - - -- <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § _ -d- - 1 <br /> Comments p . ` 11,01) (�.'f�of rYuZC� -t'ln►5 dA'� �1- TTuc TO'1p W In ca W 01 o A- o <br /> FGC1I1t1 tikrste Ke.Cr`V2( West ��^Ga'`�fOC<_ eC-IcI�YI or vJoAc- <br /> -Y\re Yemo\01 . E OT rY,arii e.As have be.,zn retatirted were rxvcx&-,I WQ_ �or <br /> vlewvr, \,) on re ues+ • V�o \/%olckAwanS or arects o� c.oneer r' <br /> Inspection Form Included: /. � � 176 <br /> , <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Ins to Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Xjl�, V I E!X A,M,P, L I E 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />