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Waste Tire Su V.-y & Inspection Repor,*Inspection Report Number <br /> ■ 1::_. <br /> Wil liilrv7 State of California <br /> B 04104) <br /> I 1 - 1088135 <br /> California Int grat dtWaseeManagementBoard Survey Form - Page 1 <br /> Part A- Survey__ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- i , I 31 <br /> � � � � � - L�LI <br /> Inspection Type (Fill one) <br /> Site Suffix: ' I Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local S G f) To ctgt�1 n C OU nt If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> `ry Truck nu I 3 cl �r 1S <br /> _ a <br /> Physical Address 1-1Qr? 1.-u CQS <br /> IIHVO Q- Ntc,MwaN <br /> Street <br /> Inspection Date <br /> Acctr�-►ac, CA g5ZZo 0 <br /> City I State ZIP Cod: Time In Time Out <br /> Business Rep Title O AM -� O AM <br /> — <br /> -T1 us. �410 FortCY)CAY) QPM L0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 73 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GLatitude <br /> PS 0 Hauler 0 Indoor <br /> O 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 /> -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§4295e Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 1g) In Compliance - No Violations <br /> 0 0 Other: § -4- �/ �l 1 <br /> Comments r Uu1 �(L12 Vn� Ct%on _ 4 of a�1L d�e `f� TTL- �y'f � <br /> K- Qty� _;�,a.. ►n o-Fed, <br /> Fc.uli�4 u��5 ►r, �oo��m1'wZr�lct� �"lre ��� t_>,a�te t1Ce removal � <br /> re-�<eGc� s�rv�c� C7T1_ bc�r► r-P—+cnryd t,.ltre. <br /> y1ife v� U �On r A=--}-. lu}ton r �.reGs o�- Concert� <br /> Inspection Form Included. <br /> Comments Included. 0"Business <br /> / a;, ) I <br /> Rep's Signature Phone Number In or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak V E X A M1 P L i F. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />