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07312040427 <br /> eye <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> �r State of California <br /> CIWMB 181(New"04) Survey Form - Page 1 1 2 - 1 0 7 3 5 74J <br /> callfomle Integrated Waste Management board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile_ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 32- 6 - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��,N To4�w,+na, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. Inspected By Inspector <br /> Physical A If ^ <br /> / Lavto�C.�o c�h'_en_I <br /> Street J <br /> n ^ Inspection Date <br /> l SAV k} . t t j5 2-0 �o I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> j3annib T 4rry 4-u P..—C4 wt-w- • M®PM LLI m 40 PM <br /> Operational Status Tire Type Business Rale: Storage Type <br /> Tire Count(Whole/PTE) . i (Fill one only) (Fill all that appy) .(Fill all that apply) (Fill all that apply) .. <br /> 10 •'Active Q Passenger ®Generator Q Outdoor <br /> I I O Q Closed Q Altered <br /> GPS Latitude 1_ .J•I-- —+ I--I�o Q Inactive Q Truck Q Hauler Q indoor <br /> �J <br /> Longitude _ ��I •f I Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 <br /> Q New Tire Dealer Q.Auto Repair Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> 7A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements at <br /> 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 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 Other: §, <br /> Comments / <br /> C R.ot..�Fm.0 1 n s�s..+ktc►�P:"r�r_rN`t °j=`—'�►-s-c�t��—Vl„l.�-G4c {-o <br /> —L.0 `- �L-�.WfAlo.�_Std'IAYA._.�_O—•i'l'/C>S_�,lte^Slt{�D --OY_►=S�,a{�._I/_�J���SQ/.�/V(14.t—�1�(-L': <br /> —l.�bco( armfi�t, J�iG Sk.— t/aicaS VLtG.n/eCl--._ 44.f(1."– ✓u�urst.—Nc7 {xGf�{s�a2cf1 opt <br /> Inspection Form Included: Q X� <br /> Comments Included:Q /� ---- — - <br /> Business Re ' ignatu one Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orre Incorrect: EXAM P L E 1 2 3 <br /> ■ White C y CI M Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> l <br />