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Inspection Report Number <br /> Waste Tire S y & Inspection Reporo <br /> StateCalifornia Survey Form - Page 1 1 9 - 1 0 7 2 8 0 8 <br /> CIWMB 181(New 04104) <br /> California Integrateded Waste Management Board <br /> Part A- SurveV BLUE OR BLACK INK PEN <br /> j Business Profile Inspection Details <br /> TPID- ` 3 7 3 6 y - O I Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: San �l T aoq Urn COUO�iJ O CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> \/a11e i ruck- {61c C2.550r ies <br /> Physical Ad 3 Ct ess <br /> &sk1 kAo\ vy)an )woad <br /> � Inspection Date Q LA � � � / C) 8 <br /> S-�oC,k�Cjr C� q5z -Z <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> ' O PM QPM <br /> 1Aox-1'� Mc,�)oncAA macre. Manager <br /> Operational Tire 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) <br /> 10 0 Active • Passenger 40 Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel j <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder 0 Other Track ��t�rdl IDR��ePct�r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Q Notice Of Violation Q Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 10 . O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ED <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 /> O 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 0 Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 ' 0 Other: § <br /> Comments Y\OLX-Vi ne tr�S c �t�ul Q� orn�e. +hls ante <br /> �_Z1-Qe.1 o-, -Tye, 1�� er P.ec hers �stY <br /> as�z kre- fg a- a� . Fnr,lltt-yis a �n�� Jc-))Un� cene.rc,�ar u3o CTl-'S �Beul�eA AAAA <br /> 1V1jqj6t_�CCl_ ZCo2R4� -C� _ � �5 Ct_# 3630kV:,-C). N.o iol la1'lns ACs n rimed , <br /> Inspection Form Included: O 09k <br /> Comments Included: ��� - — !�i�� •�'~ 6s-3(7� <br /> usiness Rep's Signature Phone Number Ins is Signatur� Phone Number <br /> r � 4 'rbaiil ri IV 62081 - <br /> INSTRUCTIONS ON BACK IE KX JAIMIPILIEI 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />