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032270400S3 <br /> �i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> I 1 - 1088117 <br /> Slate of California <br /> CIWMB1l asla r nage Survey Form - Page 1 j <br /> California IntegrateA Waate Management Boa W <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile ;--� Inspection Details <br /> TPID- t� •-�r - i I0, Inspection Type (Fill one) <br /> Site Suffix: I Z -1 / 1 1 1 O Routine Q Re-inspection Q Referral Q Observation <br /> Localc i If Referral,choose referral type(Fill one) <br /> Identifier: 5 an 7•og9ul n CO un ��JJiiII-1111 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L__GeLk�eke Ford Mer_ <br /> Ad <br /> Physical dress i Knit►an L <br /> 4CuS <br /> i Ght:rokee Ln. I _j <br /> Street <br /> O '"7 / � 5 / Q 8 <br /> i <br /> Lod CA 9.5_Z_tbj Inspection Date <br /> city State ZIP Coda Time In Time Out _ <br /> Business RepTitle O AM r j O AM <br /> 0 PM • I <br /> OPM <br /> R�ch.Ctrd ""Qn f LAVA. �Qr -• ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count <br /> (Whole/PTE)—(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r. ' Active GO Passenger Generator Outdoor <br /> - - O Q Closed Q Altered <br /> Latitude <br /> GP$ Q Hauler Q Indoor <br /> --_. .O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 40 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ( Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EMENT S1TC_,TUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 014 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§118462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations i <br /> Q Q Other: § <br /> Comments <br /> S�oyi'ine.—�nspJec+o-r��a.r or.rte -�►s_do�e��, _ollola.l��aas�_d_t' <br /> cacklty_'As_esLJ_aste._RecAv_e_r �.�e�t �taase -tire.—�ersoxal_. F'«c�lr_ty <br /> Mas �3��'�e.-kites_on�si aflT tmani es'ts }�nve be.e�n—�e�a ed _ <br /> e<Q QNL L% afar � n__.�t o Bio a'�aons er Qr_eas �t�ncer <br /> Inspection Form Included:Q u� <br /> Comments Included:Q - (% L� <br /> Business ep's SI )tatu Phone Number Insp tors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: Jtb P 11 111273 <br /> ■ White Copy. IW / Yellow Copy:Operator Pink Copy.LEA ®- ■ <br />