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y Waste Tire say & Inspection Repo40 <br /> lnspection Report Number <br /> IIsi State of fCaliforniaCWMB T � 1088120® nKV ^lXJ 1 2 O <br /> California Int grat dWaste 1 Management Board ew 04104) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- I I t�j <br /> Q I���� 17 - LQ 1 Inspection Type (Fill one) <br /> Site Suffix: 6 I —1 11 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�"� _TO 091--WO C'O U'n�y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> orfA c n _ <br /> Physical Address 1 110 Lu CQ5 <br /> Street y <br /> 0 n C—A 952-0s I Inspection Date Q O 8 <br /> CitV State ZIP Code Time In Time Out <br /> Business Rep Title. O AM Q AM <br /> D v rectw, O PM Q PM <br /> RoENI(. - - , <br /> Operational Status ire 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)111-7 <br /> ®Active Q Passenger (M Generator Q Outdoor <br /> O I Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> _.. 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply <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 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 <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 <br /> M / T / m <br /> Q 0 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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 <br /> Q In Compliance - No Violations <br /> Q -O Other: § <br /> Comments ROl+t1rw- 1`()5 I()Y) �_c{1 _. 9- '}�t� TO(i0�► r1 ( '. <br /> I, <br /> FC-C-0%+14 Utp,. , Wilsons WCAH 7j)[e CO . +6 cQ.moV! wc*s-1'eLtAlnk --ares � <br /> re_tregd USed -tvre5. VDTs have_ b e_n rmeioir2d 4 Were avnIlable Oil <br /> *1 .' :► "N0 VW-Act�1c') or areas ca c.Cr <br /> (z.a 9) <br /> Inspection Form Included Q , t <br /> Comments Included. I: _ 2 <br /> Q Business Rep's SignatureVhonimber 1 ec or's Signature .Phone Number <br /> - _ <br /> X - 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � '►� A /VI P �. E I 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />