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Waste Tire SulAy & Inspection Report« :spection Report Number <br /> aUzi; State B California <br /> 04104) <br /> I 1 - 10 8 814 7 <br /> California Int grat dtWaseeManagementBoard Survey Form - Page 1 - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile �� Inspection Details G' <br /> - - ---- - <br /> TPID- I ! I ojq I a I - O Inspection Type (Fill one) <br /> Site Suffix. I ` I II II 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -� If Referral,choose referral type(Fill one) <br /> Identifier: S on J o G q L11 n C 4 UTAJ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> �� 1 Inspected By <br /> Phuf ysical Address r Al�Q c S q,2S Q Le'n \rA\ C A I In3e Inspector <br /> � — <br /> p <br /> 112608 S . Na-60n Rd I <br /> Street ' o77 <br /> / / F-3 <br /> IInspection Date <br /> La}�r�p G A 95330 i <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> L—L - L 0PM0 PM <br /> n a CG0rnez O- c M r. —' <br /> Operational Status Tire Type Business Role S rage 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 (5 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck NIA <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill 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 /> 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 ® Other 'Tr a� { SQA 5 r��V1 CE �r <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 /> -' 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / FF1 / FT] <br /> 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 1 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Rcu-�+IBX %n�, F.":+1on r tr r ryU.,i +hip ha4e *,c 4o"01-0-- cgs tamed: <br /> Fc,clli� use� J''1 Co -rruck �1 e r 5efViCe_ �or -he services <br /> C y <br /> 41remoya\ �o�ces -�or �►re r.-emc. aVc pe�,,Jed , bu� n,un► es+� �`o�tic� <br /> \ h (.�ll� M 0 l JC _ r i r r' �'QC -rT c <br /> Inspection Form Included. 0, ARN <br /> Comments Included: <br /> Business Rep's Signature Phone Number I pector's Sid Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I XC AW R 1112 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />