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Waste Tire SARy & Inspection RepoA. &Inspection Report Number <br /> S: State of California <br /> CIWMB 04/04) <br /> 1 ® 6J <br /> California lnegrat d,WaseeManagementBoard Survey Form - Page 1 <br /> 8240 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i ' I 0 q � -1151 ,4 <br /> � � - O I � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local on J O Q ��Y1 O un� If Referral,choose referral type(Fill one) <br /> Identifier: L y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector - <br /> Physical Address 3 1 - l 0 1 <br /> I Kr1 zJ ►Gn l...uc4s I <br /> N 18 til . M aD1e tilt. i - <br /> Street <br /> Inspection Date =08 <br /> I M�r'��.cu C_A �=,,3�6 <br /> c%1� Siate ZIP Code Time In Time Out <br /> Business Rep TitleO AM 0 AM <br /> \' c L �0PM 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude � Q Hauler Indoor <br /> i O 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Li L—L <br /> Business Type (Fiil 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 /> 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <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-Registration/Decal 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 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> yokt+ty- %Y\S�A ,on Qer_'otmtd -t1,ts lock t th,e. AoIlowtoo wa ter,-o-�ecL <br /> _f pr oX. -72 U,aste ++res Jrored v+n-sloe Fac.%\\}„ .Ase Goldjzr,- G - Pr s�- <br /> -Tora �f �r em Y 1 �rom Yam Se'S . sed -tNres a CkelA <br /> f <br /> �r% IeWed No violations or ckrew- 4 cont piris <br /> Inspection Form Included: 0 " <br /> Comments Included: 0' pl;�on, <br /> --= <br /> Business Rep's Signature Phone Numb,-7rolo Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, \/ j E X A p E 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />