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® Waste Tire Su & Inspection Reporlspection Report Number <br /> State of California <br /> 181 at e Survey Form Page T + y..0 R R <br /> California Intgrd WasManagement Board <br /> Part A- Survey, BLUE OR BLACK INK PEN <br /> ;Business Profile (� i Inspection Details. - <br /> TPID- Lh_L_G <br /> , �CInspection TypeSite Suffix: ' 5 I I JO ® Routine Q Re inspection Q Referral Q Observation <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: u S arl TUGG t 11Y\ Cot Ilr`it <br /> y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> _ �- G-!s co u r..� � <br /> G i n n Physical Address <br /> LiLqJII -c—L L_i<(1-.t i Qfl L.0 CC►;�-,._.� <br /> 100 S . 5 C1 cr cA rnef)i6 <br /> StreetOH-7 � I � l <br /> Inspection Date ! <br /> Lod_.'--._ ._ __ Ctl--__�5�y a-i 1- <br /> Ci1 Stat; i'.l('Code <br /> rfrr L01�. <br /> Time In Time Out <br /> Business Rep Title O AM <br /> 0 AM <br /> ---L–. _:_ _ O – �— O PM <br /> �� I III<lrns N1�trluc er - - <br /> - <br /> Operational <br /> I Status Tire Type Business Role Storage Type( one only) ( all that apply) (Fill all that apply) (Fill all that app <br /> ly) <br /> Active Passen er Generator Outdoor <br /> xz+:: c��r?��_,:�✓��d�_s"w.�. ,rr., s i4 7,.�dN>"�Yf l-.,r.�. d�_.9���,,4in�v��� �rR��.; ' Q Q � i <br /> GPS Latitude LL <br /> j jQ Closed Q Altered Q Hauler Q Indoor <br /> [__1 <br /> � Q Inactive Q Truck9 � , IO Q Q <br /> Lon Rude — III Q Planned Q OTR End-Use Container <br /> Business Type (Fill all that apply) _ <br /> New Tire Dealer @ 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 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 <br /> Q I 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 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 ® In Compliance - No Violations <br /> Q Q Other: § - _ - -- - <br /> Comments Rr C)(_ItIrcc insia ct�on nQ.r�orrred - yw date-- _-tkk �Aow\rlj ai(.,R <br /> F ar_.\\0-j now uses racl%l�a rtir os col or -wo, -e moval <br /> Tlre� etre s�nre_d ►� n car,-�.ainQr - ure C1 <br /> t� )\r"2 Y - e Im�er -��re,, accumUl <br /> Inspection Form Included <br /> Comments included: <br /> Business Rep's Signature Phone Number Spector's Signatuoe,; Phone Number <br /> �q 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: / ErX�A f�l <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />