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Waste Tire SL ey & Inspection Repor Inspection Report Number <br /> G7ui State 1WMB California I 1 - 1088293 <br /> 04104) <br /> California Int grat df81 Was eeManagement Board Survey Form - Page 1 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ _Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I I ,I I I J �"7 - I I ( I Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: ��-An 7QC.1C�UIn CU_1Yl�u <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r I Tei <br /> + CQ r�e r Flt �ht l�.�p�C.ri 3 <br /> Physical Address _ I I I 0 <br /> C3h9 1:> • L_1na LerIV) 'J- <br /> Street <br /> L� Inspection Date l a q , 17 / Q S <br /> ` �to„kt'on <br /> ('A, State ZIP Code Time In Time Out <br /> Business Rep Title I O AM I O AM <br /> ' O PM O PM <br /> Tu fly) Z r,V_k n „ U er�� lore hk�t <br /> Operational Status 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 /> ® Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude I I I IU Q Closed Q Altered Q Q <br /> Hauler Indoor <br /> Q Inactive Q Truck ?\A <br /> Longitude — I I I iV Q Planned Q OTR Q End-Use Q Container <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 e Other I Av 1 c,+i an Se r V 1 C Q5 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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/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 /> ��ut��a. ►n���tt clr, ��.r v r;,,c;.d -�l_ �-1�tte �- --���a_�_I.vs�,r� �t .�.1�'� r ot'ec�' <br /> J <br /> NQ 1- res t,-1-ureA or)--Ife . FQt; 111+, (l­-.PS 1)- oV, tti)<:I —t-►rP Cervi poo, -Ver <br /> -�-�re� �e(dIC� r uG_k-e �u�C3 4trey rp val . F_DT Irnanthave been <br /> r :,.r I y r r i"r u� c6 j <br /> ?' c4vnrr VIi�_'.u_):.' f`, (�r�. !f. (�.!, V10 k1 1J(t U :� nCt.,.r1'1 <br /> ' F <br /> Inspection Form Included: Q <br /> Business Rep's Signature Phone Number In ctor s Stgnaturg 1 Phon ! <br /> Comments Included: Q 1 - <br /> eNumber <br /> LIE,INSTRUCTIONS ON BACK Correct: X Ak Incorrect: V !'t IA MIPI 1. Ei l11213I, 62081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />