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07354040059 <br /> Waste Tire Survey &Inspection Report Inspection Report Number <br /> 11 Sub8Cal(No. Survey Form Page 1 ' 1 6 1 0 7 3_5_9 4 <br /> CIW1at(New o g <br /> CaCaliforniaIntegratMed Waab Management Board <br /> Part A-Sy ey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j d Inspection Type (Fill one) <br /> Site Suffix: Z '7 j -/ Q (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local J—- - - If Referral,choose referral type(Fill one) <br /> Identifier: , Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name c Inspected By Inspector <br /> Physical Address <br /> �UT( G�*1 Ja QtS Z+G. q- 1 - ' I <br /> Avc <br /> Inspection DateI I Z:) i <br /> Lc�+ti.ro� CJS `1533a t - - -- - --' <br /> Time In Tim__e Out <br /> Business Rep Title Q AM ! 1 Q AM <br /> _IPM I j <br /> --- ®PM <br /> BrLi W r[.A�k VN S ✓HGN^Cr <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 /> ° 0 Active O Passenger 0 Generator ®Outdoor <br /> Q Closed O Altered <br /> GPS -Latitude O Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - O Planned O OTR Q 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 <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture Q Shredder *Other L_rcu_C."_Cc <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 /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> O Q14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations <br /> Q 1 0 1 Other: § <br /> Comments a.� 'ra- �jLs czla Sic <br /> e EzS 0 -�� tut ms=s-%;"s "P"l <br /> Ysm,_J 1c���r%>- .rc_rr -rsl <br /> Inspection Form Included:Q / S. /Vo <br /> Comments Included:Q <br /> Business R4p'§ Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: I EJJXJa MJ P Il E 1 2 31 62081 <br /> . White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® . <br />