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Waste Tire Su, _ ey & Inspection Report Inspection Report Number <br /> State <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1140566 <br /> CIWMB 181(New nage) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN_ <br /> -,iness Profile Inspection Details <br /> - O Inspection Type (Fill one) <br /> Site Suffix: S Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S 1 A�n /) o ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> St,� 50a1u,rl% (c,ut)l Cly-(kC-s Ula 3R�� <br /> Physical Address - I 0 L.xn Es cob <br /> 1 1 <br /> o S� v 9-r- AVe-. - --- - - ��U�IL����JJJJ <br /> �l CA �` ��V Inspection Date I L 05 I 0 <br /> v upon J <br /> Time In Time Out <br /> Business Rep Title /1 10 AM 10 AM <br /> P b; s �J O PM , O Q PM <br /> �ecr� V�crcQ. u 1 c,lu�,ic (�� - <br /> - - - — - --- - ---- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 ( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ®Generator # Outdoor <br /> ®Closed 0 Altered <br /> GPS Latitude � 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 End-Use • Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet • Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 (Required for NOV or EXT) <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 0 Referred/CIWMB Enforcement <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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> NO 7601U17c unwn <br /> section Form Included: � Z13o� ' �� <br /> Comments Included: gBui -�6'W,y � <br /> p's Signature Phone Number Inspec is Signature hone Number <br /> - _ <br /> INSTRUCTIONS ON BACK Correct:* incorrect ]JE X( A P E' 11 7 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />