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Waste Tire Sutfty & Inspection Report Inspection Report Number <br /> ii33ID State of California T 11088118 <br /> California Integrated fWas Waste81 ManagementBoard Survey Form - Page 1 i i <br /> 'art A_Survey T BLUE OR BLACK INK PEN <br /> Business Profile'` "� .`„ Inspection Details <br /> TPID- C)l I Inspection Type (Fill one) <br /> Site Suffix: I 19 17 19 I 1 I I ( I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I �` I If Referral,choose referral type(Fill one) <br /> Identifier: Cts 7Urt 1t1 CoUn l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `` I Inspected By Inspector <br /> Physical Address 19I Q ' Kr 15 1-I an L,,, <br /> �treet <br /> Inspection Date Q 1 / 1 i 1 1 0 I8 1 <br /> I Trevi-Em C cern D C-A °I Z 3 <br /> City f State ZIP Code Time In Time Out <br /> Business Rep Title I 0 AM 0 AM <br /> enVKorlMc0 PM 0 PM <br /> cCC1r� <br /> y C,o ocd t o calor <br /> Operational Status Tire Type I Business Role Storage Type <br /> Tire Count <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (Whole/PTE) <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> GPS Latitude I I I U 0 Closed 0 Altered O Hauler 0 <br /> Indoor t <br /> J 0 Inactive 0 Truck <br /> -Longitude - ! 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that app - €o i kA <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 0 Other Tile, I,Ann J c1cA carer i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> 0 0 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 O -- <br /> 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 I 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 Q In Compliance - No Violations <br /> 0 0 Other: <br /> Comments ,��ppC_t f <br /> R.ou��+c� � 1 ' nor �a.c u� <br /> Mate_Ck01 VAcmdln.Q for G11 - orK► - Ire- ,ztvic( <br /> f2w\0Vq\ TnN0IC1 :1zr,c,r5�-��t,rr J \e-., *,an IU '�►�e� �«�rQ <br />} E.Y2 \,I Q,_Q or vrecl,, concern . <br /> Inspection p on Form included: <br /> • �...�� �C,'::+-r Via;. // <br /> Comments Included: 0 - � � � I <br /> Business Rep's Signature Phone Number Inspeytdr's Signature _ f hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i E X TA MIP LEI 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />