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Waste Tire Suy & Inspection Repor Inspection Report Number <br /> wu3r& State of California -•. T 1 - 1088296 <br /> - �pqy //► aryq /y-�+ <br /> California Integral d WasteMB 181 eManagement Board Survey Form - Page 1 I i 1 ® 8 8 L_9 V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profilet�NOW& <br /> Inspection Details <br /> <�.r - � 1 Inspection Type (Fill one) <br /> Site Suffix: 0 <br /> 1 U Routine Q Re-inspection 0 Referral Q Observation <br /> Local ��--- If Referral,choose referral type(Fill one) <br /> Identifier: _- 1 J J Gcv,1 n Ot_lf)� <br /> Q CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> �Lr ��Ylctn MOtarS _ FTF LI <br /> Physical Address ' (� I_: r <br /> haa <br /> Street _ - / <br /> -U Ckt� C q Inspection Date Q / I U <br /> ---- _.—f_�.,eta-te ZI/� y Time In Time O`ut' t� <br /> Business Rep TitleQ AM Q AM <br /> O PM 1.__� QPM <br /> • ��� Business-Role —Storage <br /> T <br /> yO erational Status Tire TYPep <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap <br /> ("a� w,�IOL r ,;,I � Glp � 1�y ✓ a A I I , <br /> Ire, "� �rr( �g., ., • G . .}µt;;'Z. r ,.r •IG4.,;"a ' 9 Active O Passenger (3 Generator 0 Outdoor <br /> ��� _._ O " <br /> Latitude � � Q Closed 0 Altered <br /> GPS J " <br /> ��� Q Hauler 0 Indoor <br /> -- <br /> 7 Q Inactive O Truck <br /> Longitude – ` t Planned 0 OTR Q End-Use 0 Container <br /> • <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body ® Car Dealer O Collection O Crumb Rubber <br /> 10 Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 111 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IE / III / IE <br /> 0 Q 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 l <br /> (9)Q Q Other: § in Compliance - No Violations - <br /> _ <br /> Comments tr�lUfl T <br /> o ung _t:_.r o r mR(A +1 I� � 'I ` � 01 I i,,,►� �,7�r_� <br /> x 125 uta e use _ �rc� ar,-L1 - acyl u �e`� Lcik�n -T re oe - <br /> 0 CA_ EUT r art I hO1/ e n r i�'r-e P <br /> V, _ ,1 t i�.l_ ; .r q } , . r -- r <br /> - - - <br /> Inspection Form Included: O <br /> Comments Included: Dr _ <br /> Business Rep's Sign Lure Phone Number in Vector SS tuphone Number, <br /> INSTRUCTIONS ON BACK Correct:® incorrect: v }� 11, 12 3 <br /> 62081/� + d�!"I ' <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />