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• <br />• <br />08157040088 <br />ere. <br />Waste Tire Survey & Inspection Report Inspection Report ■ <br />■ °° stateofC1(Ne'a Survey Form - Page 1 1 3- 10 7 9 Number <br />2 3 4 <br />. CIWMB 181 (New adage) Y <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site <br />Site Suffix: <br />/ <br />D <br />62081 <br />-/ <br />., <br />C� <br />5 <br />Yellow Copy: Operator <br />Pink Copy. LEA <br />® <br />Inspection Type (Fill one) <br />/ • <br />f <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) - <br />Local <br />Identifier: 5A <br />✓ f�. _ <br />( <br />Q CHP p CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />� e!�—�u.N�j <br />Inspected ByInspector <br />Physical Ad ress <br />24 AJ, AJ. deio_kt° e- 64 I <br />Inspection Date O <br />Street <br />G}' <br />O /+ 52.`10 <br />I �I, Com- ! I <br />Time In Time Out <br />0 AM 0 AM <br />MOPM [1] m <br />City State ZIP Code <br />Business Rep Title <br />L_�% ✓ 1 C �� J <br />0 PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />—J — - <br />- --""'" 7�f�� <br />A <br />Tire Count (WholelPTE) ° e �. ! ; <br />r <br />®Active <br />Q Closed <br />Passenger <br />Q Altered <br />®Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />GPS Latitude LJ <br />I i <br />I� O <br />L—i <br />-J —J <br />Q Inactive <br />® Truck <br />Longitude _ <br />-i_-i-.1 <br />I IO <br />1 ► __ <br />Q Planned <br />OTR <br />Q End -Use <br />Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator; Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956-.Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />/ m <br />Date m / Ffl <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR §'18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred I CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />In Compliance - No Violations <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments r,� 1 <br />Or�27N� /A)5C,_�r��nl �'1_//SLS—�i�TG_.—/_//� TZJ��G_c�Ji'A/ <br />q <br />—�✓oT-'� ' �i3—�I ''� � -—��'"�' lrro�e��—�� ��� ei%u��_..ss�—i— <br />fr(/r4nl i -F v 11 (� ,G E{%a ✓ 0 , (�JsJ�_ <br />�1;LG.or_t_l.Pit-f�S—^J_oT� <br />Inspection Form Included:Q <br />� <br />Comments Included: Q <br />o <br />•G <br />siness Rep's Si re Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK <br />Co recta <br />m r �( <br />Iyn orrect:+ LvJ <br />X AA P L 2 3 <br />62081 <br />■ <br />White Co CIW <br />Yellow Copy: Operator <br />Pink Copy. LEA <br />® <br />■ <br />