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08OSSOS0003 <br /> Waste Tire Survey &Inspection Report Inspection Report-Number <br /> < �a State of Caigomla <br /> CIWMBI8I(r-041e4) Survey Form - Pagel 1 3 - 10 7 3 3 5 2 <br /> Califomla Invetegrated Waste Management Board <br /> Part A-SurBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> Site - / Inspection Type.(Fill one) <br /> - <br /> Site Suffix: l` ®Routine Q Re-inspection Q Referral Q Observation I <br /> Local �1 If Referral,choose referral type(Fill one) <br /> Identifier: SVQgy�,l(_/L. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> A �- <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physicaall Address <br /> I SyVa ibs I 3H _ Mb11 I )C/-z)Z_ <br /> t y MeA oK Ave j <br /> Street ^ ' /,r p� <br /> 1 '71— ( s33� Inspection Date O a I V 11 <br /> I w1 \J^ v 1 Time In Time Out <br /> City State ZIP Code <br /> Business Rep �•- Title m'MOAM <br /> 0 PM m'm 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> it <br /> C)Tire Count[Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)rU <br /> ®Active ®Passenger *Generator Q Outdoor <br /> Q Closed O Altered <br /> O <br /> GPS Latitude Q Hauler Q Indoor <br /> r I Q Inactive Q Truck <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 ®Other I � .tr <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler-and End-Use Facility ENFOORCEMENT S1TATUS <br /> V A11111AULING M DI MR I F E Mjffil REQUIREMENTS <br /> ®Notice Of n Q xt <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires ViolatioEension <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 / V g <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB v v <br /> Q Q (14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXT) <br /> ® 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 n �� 1"jp�. 6-' . <br /> Read" t,Ci o ! V'� r (/l�Q <br /> � �f �J��VW��IJ� �1-tL0. i� � ND �vas�t-e dire <br /> wiapvz Fz�sf� �tv_ _ a V�ov4ri a <br /> I R Lf E�9, s--- - TKO LoS — 'n <br /> Inspection Form Included:Q <br /> Comments Included: Si 6.Rep's Signature Phone NumberX spector ignature Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> EXAA4P `L �': JI-1213] <br /> ■ White Copy.CIW MI3 Yellow Copy.Operator Pink Copy:LEA ® ■ <br />