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- Waste Tire Sy & Inspection Repor Inspection Report Number <br /> 3K State of California <br /> COMB 181(New 04/04 Surve Form - Pa�uye 1 Il - 1088122 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection <br /> Details <br /> – – - – <br /> TPID- l 2 Type (Fill one) <br /> Site Suffix: IRoutine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sc1Y) 70Caq Ulrl COUY'� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C u n h G r a `r"r�c _ _ _ <br /> Physical Address K.rlstl.arl Lta C�iS 0 <br /> Street j Q <br /> Inspection DateCA CJ'53-�,01 � G� <br /> EE. <br /> e InLTime OutState Llf Gone TlmBusiness Rep Titl . O AM <br /> PM I � T 0 AM <br /> _ � � � PM ' <br /> _�_rcand'E-+ckl ho ►_Grcrnc,:n� <br /> OperationalStatus Tire TypeBusiness Role Storage Type <br /> only) <br /> that <br /> (Fill all that apply) (Fill all that apply) <br /> 1 � <br /> f ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GIBS Latitude t 0 Hauler 0 Indoor.—Ld. <br /> 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Ail 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 /> - - I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - --li <br /> Notice Of Violation Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS O O <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§42956-RegistrationiDecal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days -- -- — _ <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsS�CJ_\O } str 1 v 1'x,2 j i`� sa Wit_1:� '� i o <br /> n.o c81\-Vl U-"5 t1cCa :Truk _fie_ Sy�cCn+cr ur v cc ic/_ <br /> unk -,l,re rel-novn <br /> ro_. _ a�tc --\fes ccr _�-�� cn- Ike . <br /> f <br /> v�e W ecl . (R!r, < 1 C'� i C)r s or _ r :a ;� _.anc e r r.d <br /> Inspection Form Included: (� " Stu <br /> Comments Included: 0 .- _ <br /> Iciness Rep's Signature Phone Number lspec[or s Signature -, Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X r . <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I, <br /> iG— <br />