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0829040880 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ClWM III <br /> Survey Form - Page 1 11 - 1 0728241 <br /> CIWMB 781(New O4/04J <br /> Calitomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> { TPID- �1 11 <br /> Inspection Type.(Fill one) <br /> Site Suffix: �L` 1 I I - (/ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: py,) 1i OA Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> �'t'r_.i/tf N <br /> Business or Facility Name - <br /> AlInspect(ed By Inspector <br /> hi ysicalAddress fr0�M Ori - D2� I / <br /> L 2go5 /U 4/ �)VeZ4do ST' — <br /> Street <br /> Inspection Date •D � / 1 5 / U 8 <br /> I�7QG,vT_D � 95?1�5 <br /> City tate Zip Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 1 / m:F70 <br /> 0 PM m 0 PM <br /> ---J Operational Status TIre.Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) / . . e 3 i- <br /> Active 0 Passenger •Generator ®Outdoor <br /> ! i <br /> Latitude I O Q Closed Q Altered <br /> i' GPS I t Q Hauler Q Indoor <br /> L----I I A -.�� Q Inactive Q Truck <br /> Longitude - I I �- 1 I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) L <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet .Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 — - <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility KENF.O.C-EMENT 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 Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / LLJ / 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 EXn <br /> Q 0._ 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 HaulersQ Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q 1 Other: §, <br /> Comments <br /> —��t,T%„��t��p-fr�i_c...i—ey,—/�+.rs�•'s-�71+>�—Fr'ua��,rcf_c.,tis-�or_E�•_iLrs—�,src%,dt <br /> zhe- -!4�!•S_ 1juT_E—T�2� Ns►stIt 994A&** _r <br /> fa�c /`l CCQ � s � 3_ uis <br /> _ _ <br /> I — <br /> 3 eAfS ons%>' _ AL/e- �Js e' A I <br /> QQ p <br /> Inspection Form Included:Q <br /> Comments Included:Q - -- <br /> Business Rep's Signature Phone Number Inspector's ignature Phone Number <br /> 62__ <br /> INSTRUCTIONS ON BACK C t7, Incorret I�1^Ia M P;L 1 2 3 <br /> ■ White CoYellow Copy Operator Pink Copy.LEA ® . <br />