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07312040444 <br /> Waste Tire Survey & inspection Report .. Inspection Report Number <br /> err <br /> rr <br /> State of <br /> CaliforniaSurveyForm - Page 1 1 7 - 10 7 3 3 2 3 <br /> CONMB 181(New 0410{)CaliforniaCaliforniala Integrated <br /> WbWasla Nanagament Board <br /> Part A'-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - / O ,r�i�� Q ! Inspection Type(Fill one) <br /> Site Suffix: L'� (/ I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local —_-}- _ If Referral,choose referral type(Fill one) <br /> Identifier: / _ _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> or�Facility Name Inspected By Inspector <br /> 1 syya ' ' - I L��/�� - / D r L\� N�tr <br /> Physical Address /// sie <br /> 13_� �U� - <br /> Street <br /> renes, C � 95z J l Inspection Date <br /> 611YState ZIP Code Time In ( Time Out <br /> Business Rep Title0 AM <br /> m O PM:m m m O PM <br /> Operational <br /> IStatus Tiro Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ! e i (Fill one only) (Fill all that apply) (Fill all that appy) (Fill all that appy) <br /> Vi WActive Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude �,�— —� OH.auler Q Indoor <br /> o <br /> 1 Q Inactive ®Truck <br /> Longitude - 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 l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULI G Nl)MA IFES REQ R NTS Q Notice Ot 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- esposibleRegistration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (R ulred or OV 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 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 ®In Compliance - No Violations <br /> Q Q 1 Other. § <br /> Comments �rl al, ��+llGr�- 7Ai C fac <br /> 7?le - ((/e `ar�r✓I Ce $ Deo a e t �S K;wed e( fly, <br /> Inspection Form Included:Q fol <br /> Comments Included:Q — U� IIL <br /> usiness ep's Signature Phone Number ecto s i atI. a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Incorrect: jPff[AjMj;rL1E1 1112131 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> 1 __ <br />