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09210040580 <br /> Waste Tire Survey &.Inspection Report. Inspection.Report Number <br /> State B 181CaliforniaNS u rVe Form - Page 1 1 8 - 1 0 7 9 3 7 0 <br /> Cgrated 1(New y <br /> California Integrated Waste.Management Board — - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- In <br /> spection- Inspection Type (Fill one) <br /> Site Suffix: b Icz O 1 a Routine Q Re-inspection Q Referral Q Observation <br /> Local `�.,^ If Referral,choose referral type(Fill one) <br /> Identifier: � l,Cky(� �_N <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> L__ al <br /> I 1 ►'0l�h i_,_L L_C, <br /> Physical Address — Illoll] L&"1, <br /> ruy ��,��I��'�WW►���lll <br /> Street p� <br /> Inspection Date <br /> City� �� State Z!P Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 3 ' 15 O ® PM 40PM <br /> Operational Status Tire Type Business Role Storage Type <br /> . I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> I ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude ` I Q Closed Q Altered <br /> GPS Li I— 1J i Q Hauler Q Indoor <br /> Q Inactive le Truck <br /> Longitude - _171 Q Planned ®OTR O End-Use ® 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 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 —11 <br /> / 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 EX7) <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 ®In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> i�e�rns�_e_G-h�aa�-�e c�-1�n►S ac,,,�as 'the <br /> Inspection Form Included: Q <br /> Comments Included: Q B *1nesine Rep's nature Phone Number Phone Number <br /> 62081 <br /> INSTRUCTIONS ON ACK C rrect. ncorrect: I EJJX I A hh P 100 11 2 3 <br /> White Cop :CIW Yellow Copy.Operator Pink Copy.LEA <br />