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W' <br />® aste dire S0✓'4 & Inspection Repo*46spection Report Number <br />Hill <br />of California ■ <br />p -CIWMB1811 (New04104)Survey Form - Page 1 I 1- -1088245 <br />California Integrated Waste Management Board _. <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />TPID - <br />Site Suffix 1.751.jL <br />-__ —V._ ._...:_._ L 1G— --1 <br />Local - <br />Identifier: Q h 70 CSC U 1 n <br />Business or Facility Name <br />Physical Address <br />1 1 D 5 0 0 M c.lh k n l e� _ �(A <br />Street <br />LG 1-hry CA _ 95-33( <br />City –� - State 7%P Code <br />Business Rep Title <br />�All ira,5a)e� Direc_ror <br />G PS Latitude I 0 I <br />Longitude – <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Inspected By Inspector <br />3 9 alFll Lu��i��-1 <br />Inspection Date <br />=08 <br />71 <br />/� <br />v <br />U� SlTime <br />In <br />)JA`,`1A P I JEJ <br />Time a out <br />SWhite Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />® ■ <br />0 PM <br />0 PM <br />Operational Status <br />F,Mf ire Type <br />Business ess Role Storage Type <br />(Fill one only) <br />(Fill all that apply) (Fill all that apply): <br />® Active <br />® Generator 0 Outdoor <br />0 Closed <br />)1, <br />0 Inactive <br />u I <br />' '�"�� <br />0 Hauler 0 Indoor <br />`? <br />0 Planned <br />0 End -Use 0 Container <br />Business Type (Fill all that apply) ;I <br />0 New Tire Dealer 0 Auto Repair t@ Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 ! 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />m/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Comments Included: U"✓ <br />Business Rep's Signature <br />Phone Number <br />"'117-14 't, c > • <br />lopsc#ors Si nature <br />9 -_ <br />_ 1' ' ; / 0 <br />Phone Number <br />.... <br />INSTRUCTIONS ON BACK Correct: ® <br />Incorrect: X � <br />)JA`,`1A P I JEJ <br />62081 <br />SWhite Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />® ■ <br />