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=e Waste Tire Subey & Inspection Repor', Inspection Report Number <br /> State of Survey Form - Page 1 ( 6 - 1 0 l 2 $ 0 $ <br /> CIWMBB181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 3 - Inspection Type (Fill one) <br /> Site Suffix: J O0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'DGM J oagLttrt COL1YVVQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> NI i d v a\1e 7 P Gste t''t A9 3 1 1 0 1 <br /> Physical Address �t'1s�1gh L Ar-cts <br /> 15300 5- A\/- . <br /> `_ Inspection Date � 3 � 2 '7 � 0 <br /> �.Ot}hr0� QCJ33� Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> S,�S J��anC e O PM O PM <br /> Sox\&ck Grav\i- Brown istrcktof- - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active Q Passenger 49 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4D Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 <br /> W. -a l�►_ x,: tce to i ensr <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 o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / E <br /> 00 14 CCR§18459.1 -Tire Program ID Number from CIWMB m <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> Q o 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Vlolatio <br /> S__ <br /> . <br /> 0 o Other: § I` <br /> Comments <br /> o vI -fQAOWt no ras <br /> ,X� vt d € <br /> Fac-,111�-- _uses 13iranyion -C%Y'e. -&or 6�ya((''Ae, -t►r,, Vios.\�nnq CTL rn �es-{- <br /> ani- s 4taye n <br /> Ia <br /> XQ-_ �- <br /> Q1� A were �„c e cxy n t\C40ke &r 1 ec+to NAo -j l dk o-It-1 erns ar a,(ea <br /> Cd(\C.erns InoAnea <br /> Inspection Form Included: Q 3I-e 'JO <br /> Comments Included: Q — - -- <br /> 6 -317 It <br /> ms Rep's Sign re Phone NumberIns or's Signature Phone Number <br /> � _ 62081 <br /> INSTRUCTIONS ON BACK torr c nco �c . + P 3 <br /> �� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />