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' Waste Tire Suiey & Inspection Repo Inspection Report Number <br /> ® Wi,ji <br /> State ofCaliforniaCIWMB 181( e ) Survey Form - Page 1 I 1 - 1088001 <br /> California Integrated WasttManagement <br /> Waste Management Board y. <br /> Busm_ess Profiley- V- _ Inspection Details - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> I � O I � I � O � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ''— If Referral,choose referral type(Fill one) <br /> Identifier: snn So Gqw n C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L-3 �_jPhysical Address� "---- �� _ li Q I <br /> I 3? 5 O M �,nkord_ Ayf . <br /> Street _ <br /> `.� Inspection Date <br /> City! State �Cotle <br /> -"� Time In Time Out. <br /> -` ` <br /> Business Rep- -Title(('[( O AM O AM <br /> OQPM 0 P <br /> t y15CA V) .er , - <br /> Operational Status Tire Type Business Role r Storage Type <br /> { (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply): <br /> fi ® Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude !�`Ltd � Q Hauler Q Indoor <br /> �D Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that ppI <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 /> t <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler nd End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Ti es <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 I Date m / 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 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 Q Referred/CIWMB Enforcement <br /> Q i Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q I Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> \n_J�ec__or, (y\ZC_4 +1'► da'tc -- AL4011owlyv W os <br /> Y)OtC4 : T7cA St�Ja4, �f"r,�Lk "Ire ✓ice erv_-►ce <br /> wage �Clr2rcrnav rl�_\n <br /> pct- C }I1r� Y(1 C �` Gln �f +Y 'ths or� �r,• <br /> Inspection Form Included: Q — <br /> Comments Included: ✓ Signature <br /> ign`ar turf _ Phone Number <br /> _ - <br /> ins ctor's Signature Phone Number <br /> — - <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: 62081 <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />