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Waste Tire S ey & Inspection Repo Inspection Report <br /> State of California - <br /> Cgrated Waste <br /> eManag4) Survey Form - Page 1 F g 1 0 7 3 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I t I i I l� I I J 0 Routine 0 Re-inspection 0 Referral Ij Observation <br /> Locall If Referral,choose referral type(Fill one) <br /> Identifier: S�� TOGO�I't 1�1 O`�h t \ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L - � 1nrn.e. L� ro unf-$ - I d I <br /> Physical Address <br /> I �C 1:t:1 in Luc (-i,<, I <br /> I q , C:t . I <br /> Street <br /> Inspection Date <br /> Cify State IP Coe Time In Time Out . <br /> Business Rep Title r_E : <br /> L_F7 O AM O AM <br /> 0 P 0 P <br /> nrn C - - <br /> Operational Status Tire Type Business Role Wtorage Type <br /> Fill one only) (Fill all that apply) Fill all that apply) apply) <br /> Fill all that <br /> Tire Count (Whole/PTE) ( ppv) ( pp y) ( <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> r <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR 0 End Use 0 Container <br /> ___V <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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (j) Other >>c. Ys.l�, tc3n {T) <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 011 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§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date F11 / 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 /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments Na <br /> - 1�' <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - --- --= - - <br /> Business Rep's Signature Phone Number Inspattor-s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �, i I~ X1 A MI p I l_I El 112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy'LEA <br />