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Waste Tire Sulay & Inspection Repor#lnspection Report Number <br /> ` 43u:.w8 State of CaliforniaCIWMB 181 ew 04104) Il - 1088140 <br /> California Int grat dWaseManagementBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileAlk _A Inspection Details <br /> TPID- I A 3 Z Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local . � J l If Referral,choose referral type(Fill one) <br /> Identifier <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ,.Business or Facility Name Inspected By Inspector <br /> ;y Tf�1�Cr Sa�eS � - i I �1 <br /> Physical Address _ V I <br /> � Kr,si-�an >,ucos � <br /> i a L-(nU C, OCAT \ar Rd. <br /> Street � <br /> _ Inspection Date -7 2 G 8 <br /> I Fcp-n crh Cern p CA G 5231 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' L 0P (QPM <br /> end <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTI.-AL <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> C ® Closed Q Altered <br /> GPS Latitude I I �I Q Hauler Q Indoor <br /> I i0 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 0 Other -T(Q l(er ~G'e S/se r VI c e, <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 / 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 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 Q In Compliance - No Violations <br /> Q Q Other: § J <br /> Comments KO�1�1nSL rr CiicZ►� lU(�t 1� Gl 4 _trL� �O�_�oW1f U _ _ t Ac <br /> No 41TQS zne1rg}cc1on-s+ '('Mons %.sere 0-e)ter conduct e -}�►� <br /> �I <br /> 10�_C,t10Y1 bECQt►�,e- +ON`- .Caddre JO C`l rno-� extSt. OtNI►�u TrGlle r Sg1eZ1 <br /> o rad aLA of 1_Z S S Holman f, La ro— g533 Tr` � �_He -o� <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> 5�_4 <br /> Business Rep's Signature Phone Number _ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X /p V !: M P I (r Z <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />