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08206040090 <br /> [e <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> 'iQ scam of wrror�la . <br /> CIWMB 181(N..04/04) Survey-Form - Page 1 1 3 - 1 0 l- 9 2 5 9 <br /> California Intograted Wasta Management Board <br /> Part_A-Surve BLUE OR BLACKINK PEN. <br /> Business Profile ��-- Inspection Details <br /> TPID- 4 I .r- [_[�3 O ' Inspection Type.(Fill one) <br /> Site Suffix: El <br /> I 0'Routine Q.Re-inspection Q Referral Q Observation <br /> LocalQ If Referral,choose referral type(Fill one) <br /> Identifier:. ..'JQn -'ogquin. CoQt O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L- LL i-tt A.I.i 9 nfri2�n+ Se ry i cQ l _ <br /> Physical Address Q ' <br /> LKri_s��an L wcagJ <br /> I—C[25 S. 1 'Dor4do— <br /> Street <br /> Inspection Date <br /> 5ta ckt�r C1A 95 <br /> ity State Z p Code Time In Time Out <br /> Business Rep. 1 Title O AM O AM <br /> OS 1 Qt L_ I m <br /> MOPM <br /> m- O PM <br /> .-C <br /> Operational Status Tire Type . Business Role Storage Type <br /> ! {�� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> -+I 0 Active e Passenger ®Generator 0 Outdoor <br /> Latitude I Q Closed Q Altered <br /> GPS J OH.auler Q Indoor <br /> O Q Inactive *Truck ' <br /> Longitude - Q Planned. Q OTR O End-Use Q Container. <br /> =,I <br /> Business Type (Fill all that apply) 1111 <br /> Q New Tire Dealer 9 Auto Repair Q Trucking Fleet Q Government Q Retreat der Q Dismantler O Tire Dedved 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 Q Other 1 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS otice Of Violatio Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers.. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14-CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CI WMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O 1 Q Other: § <br /> Comments <br /> tnpovi�+n� 't►(3 rydr�xtiec�_-- t�9 - cft -t4.e a�1 unit <br /> f�-0h cl.'F7 .i�t�a is a 1 d�+.�V_oS�m �n e_:f r r ►�e S�s Qx. - <br /> -l�{1 +Iti a t' �h�tes� �ro�rt �����cs1�•,� �►et0e'd <br /> Inspection Form Included: Q z0% Czo4) <br /> Comments Included:O, - - - -- - -- -qA- �� - � " Aq6$-WO <br /> si ess Rep's Ignature Phone Number Ins to11 Signature Phone Number <br /> - - - - 62081 <br /> INSTRUCTIONS ON BACK CorI correct: AIMAIMI P. L E 1 2 3 ■ <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />