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y Waste Tire Su & Inspection Reportpection Report Number <br /> State B California ry I 1 - 1088009 <br /> Cgrated Waste <br /> eManag) Survey Form - Paye 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile_ I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 13 I I �' 13 ► 6 "� ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: %Ar; .SO rA ot i 1'r1 C,O U n1 v <br /> i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C13nS�rutLk10T) C.o I 2 - <br /> Physical Address <br /> Street Inspection Date <br /> � <br /> I� �re'n C.�, C'ct��p CA 9%n� I <br /> City State Zip Code Time In Time Out <br /> Business Rep Title I O AM O AM <br /> CnY1fOYlr'xznAc.>> O PM O PM <br /> I Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) # t Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> h_ 0 Active Q Passenger ® Generator 0 Outdoor <br /> I " Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Ii I I <br /> I i � <br /> Longitude Q Inactive Truck <br /> Q End-Use Q ContainerI Q Planned OTR�Q <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 ® Other C OnS-A L U C} to 11 Co . <br /> . <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 ® 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/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 O In Compliance - No Violations <br /> 0 0 Other: § --- }r <br /> Comments F,0._11� 1Y(1��C-Lo ���drl�3 }�11% AC1Ae F( 4v IOIIAWIna ijo5_ )a <br /> F-a(-t 16A j CAAC QfNAI u)t\.s on Uj -TIr9-- o . to( WQ-tc- �I to r e roCjVq <br /> AS, �'y rcR S 18yr�`� .3 1,e.�e(ttan c� Comm re�unSlVe —frit Loos AGr -� 4Ls <br /> e�er<A vnGnl -Ts tier not- available for VIEW%() <br /> Inspection Form Included: Q - <br /> Comments Included: '�— <br /> Business Rep's Signature Phone Number I pector's Signa Ph <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,�, \/ I E XIA MI P I L I E1 11 t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />