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Waste Tire Suoy & Inspection Reporolnspection Report Number <br /> _���' State CIWMB California I 1 1 Q 8 812 4 <br /> grated Waste <br /> eManag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile In Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i I o I I I I-7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local —T If Referral,choose referral type(Fill one) <br /> Identifier: G��"n TocGqu%n C0u�A 11-1 i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> Jer�k�rf oulfiry Fctrr,\S <br /> Physical Address — I To 1 L Kr1Sti Cln Lucas <br /> Street <br /> _ Inspection Date <br /> I <br /> DC)Y) �� �5'�66 I Time In Time Out _ <br /> C%rV State ZIP Code <br /> Business Rep Title 0 AM Q AM <br /> 0P ' _ 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)li (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m Q Hauler Q Indoor <br /> ® Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all thatapply) <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® 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 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: § <br /> Comments <br /> No 7V\1f4eL_ 5torec\ on-,i+'e Tenk►ne- 'o" 1tr.►,, �urmc:- __ - din Qulk <br /> Fn"kt(� Farre_.. (Tip►p * 1S314 ►5—015-01) nn!e bath r, rt C�1 Vc-' e- <br /> T--a"lrns l-L-C. . Ten k1 ns poyFtta 'i�orm-�, nn _je)nae1r operrAes 6 7trL Cc - N\eck <br /> I ccs c,V(ren 1V rate(I n It k t)-OM r forms (TF 10 1!:3 lS 41� <br /> Inspection Form Included: j <br /> Lt <br /> Comments Included Business Rep's Signature Phone / <br /> Number 7spector'signator � Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X Ak V 1E Xj'A-MJPjLjEj Ill Z131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />