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Waste Tire Surfy & Inspection Report Inspection Report Number <br /> 'orniState CIWMB California I 1 - 10 8 814 3 <br /> a grated 1st(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - <br /> " TPID- I 1p 0 r 6 G Inspection Type (Fill one) <br /> Site Suffix: ' 3 l I I ® Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C ri Yl 7o G 9va I n Ccs U nt <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 3� y 1 Q K ryt I an LU Cc <br /> 2 Co(oo L OOMII 12,d . <br /> I <br /> Str•et <br /> Inspection Date G —7 3 Q <br /> i Seo 'Mon GA I5 Z t'� I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title I I 0 AM 0 AM <br /> 0 PM 0 PM <br /> PGrtS Mat <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1316 �I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger i Q Generator Q Outdoor <br /> t' Q Closed Q Altered <br /> GPS Latitude . I I I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> V <br /> Longitude — ' i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 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/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: § <br /> Comments <br /> QOtuat-i0e, r7�4wC_1k0r) �_f�orWV-H -fhIs (I a+( $ t�rz �c�l�ow�n�t ���►��:_c� �t� . <br /> �c►c j uses - if'P_ LCr1'�e'r5 �c)r - ifE &-kive-ri 4 wo,_te_u<ej t►rc <br /> Cmoval . CTL. (Y)CK) e-zt5 have. beer, re}u1ne were (watlGble �or <br /> VieW%y) r \-I .3y) fEc_ oel,t • ,n em r,� t�t►e Com`.__. rr ant�e�-ls Ie�ck��! G <br /> -- -- - <br /> Inspection Form Included: Q ,✓ <br /> Comments Included: jp <br /> Business Rep's Signature Phone Number 1 e or's Sigre , Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �, V IE- X i A MIP, LIE) I i 2J31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />