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Waste Tire Sua & Inspection ReporAospection Report Number <br /> La CIWMB 81California <br /> (New04/04)4) Surve Form - Pa e 1 Il - 1. 0 8 8 0 0 8 <br /> California Integrated Waste Management Board g <br /> 'art A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile _,Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 118 I - 0 I ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C!f o(trt(.1 t r C cru n y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> ��u c.ks I � <br /> I I - <br /> I 0998 5 . Hnx- lan P,c I <br /> Street <br /> Inspection Date <br /> FYenc1� Ccs C,A 95 z.li <br /> h, State ZIP Code Time In Time Out <br /> Business Rep Title I O AM O AM <br /> Lense Q PM O PM <br /> �J�►11 \am Voud . A(r014o Mar . , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE I � � � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> U Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> v <br /> Q Inactive Q Truck <br /> - I I I Q End Use Q Container <br /> Longitude <br /> i Q Planned L Q OTR <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 I HAULING AND MANIFEST REQUIREMENTS 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 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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments llL <br /> trlQ Irl -2G'�ldCl �2YlOY �� V� �Gt� 4 -4i- � 0�'C7WIfi r��Q <br /> J - <br /> r�c���d V-ac*.6,i hay old?(QX . �i _cd -t - -►res on - 5►f� . <br /> 'F o, WlLon uJo� `T re Co. $ 0 _Co � rt( tuck 7►rz SzrVice- <br /> Cen�zC , enc tte- _eC V►cL `F rQ'MOYal1 <br /> Inspection Form Included Qi. <br /> Comments Included Q <br /> business - -- — Phone Number / Phone Numberp nat <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: X �, V I A MI P l 1 EI I 112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />