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-A <br /> Waste Tire SO4ky & Inspection Reporolnspection Report Number <br /> at <br /> Sate of California T R 1 n/ <br /> 04/04) <br /> California lne grat dC1WMBt81 WaseeManagementBoard Survey Form - Page 1 i 0 `' �^ i ` <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business; Inspection Details <br /> - <br /> I TPID- � _ Inspection Type (Fill one) <br /> �Ll _ <br /> Site Suffix: 1 I `� I Q Routine Q Re-inspection Q Referral ® Observation <br /> Local Ulrl CO UI It If Referral,choose referral type(Fill one) <br /> Y,,Identifier: G , <br /> TOa <br /> 9 J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> "XI �AoII nca A1► nrwtnt ' r <br /> Ph 3 _ <br /> sical Address <br /> Physical I K.r ~t�t ter, Lucas I <br /> Street <br /> Inspection Date <br /> I Stc,C,k't`or CA 9,5 Z 15 � <br /> - State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> _ ' � QPM � ' 0 P <br /> r`kndre� Mcdting 0UJner I - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger (9 Generator t)Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - 0 Q Inactive Q Truck <br /> Longitude - f <br /> g Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) T . <br /> Q New Tire Dealer ® 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 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 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 /> 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 In Compliance - No Violations <br /> Q Q Other: § 11 <br /> Comments _Tt'11- y-%k _ 1 S "�'► 1 •Q1 TOfMQ-C�-- -}�'11S do+e- 0laL1 (+ _j14-L-a: <br /> rax ._ 1,5 WQsfie -fires s+ortd car,-_ lie. F4cdl+, Cznlf} generq+ce o 100 — <br /> ` J <br /> 200 WW-*e -xrp pe -9- GCI lI+i.! -TrA - CC -Tire li�ecgckr -- <br />} dor e_ ,r►re rernoy o� . r IeCtr . C7L <br /> U t -- - da_�C Cl - 1 <br /> Inspection Form Included: <br /> Comments Included. <br /> Business Reps Signature Phone Number I ector s,Signat� Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X le <br /> X A �, PIL E S I I 2-'131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />