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C8234�4004� <br /> " o Waste Tire Survey & Inspection Report Inspection Report Number <br /> ::••o <br /> State oCa ena [_I1 — 1088168 <br /> CIWMe18;(N-041N) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Sl' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O Q 1 - O + Inspection Type (Fill one) <br /> Site Suffix: '31 ` 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local — Cot�ty If Referral,choose referral type(Fill one) <br /> Identifier: Sore TOOLC�ut r+ r'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected'By Inspector <br /> TO 1 KrlStian_(..ucns-J <br /> Physical Address <br /> I 82o 5. C1 Z A_v_2. I <br /> Street Inspection Date Q S Q 5 8 <br /> L -Lcd; __ CA 9sz�oJ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> V&_11 CSR m•MOPM O PM <br /> Oral lrJf�.h} t—MgLn ._ K "•'t Operational Status Tire Type Business Role .Storage Type ' <br /> 'Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply)-,.(Fill all that-apply) . <br /> Active Passenger 0 Generator t♦Outdoor <br /> I I 0 Q Altered <br /> GPS Latitude I I ,I Q Closed Q Hauler Q indoor <br /> O <br /> --- Q Inactive Truck <br /> Longitude - II Q'Planned Q OTR Q End-Use Q.Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use-Facility ENFORCEMENT STATUS _ <br /> V M I HAULINGAND MANIFEST REQUIREMENTS 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 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 Haulers Q Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities, _ <br /> i <br /> Q Q 14 CCR§18462.-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In amHance - No Violations <br /> Q Q Other: § ` d C <br /> Comments p �l"1 on p4,.'C�O�MQG7�—�"• 4 `ry►_-�.__'TO <br /> 'Ti r¢ A r �fiLr�at ¢�erg 1 cst w_asi�- .moi�e— <br /> rtmAVQe C=. L manAe5t5 have htalla rietainv_d 0 (_ag". w/0 abt4 &r <br /> wet ri—tc . t.e s - KJO �o�`f J g or art a s;_ ts� .O_n _ern_ <br /> Inspection Form Included:Q r Zoa <br /> Comments Included:Q - <br /> B Rep' nature Phone Number Irl ector s Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rr IN 111. Incorrect: 'LaX A M P L L 2 .3 <br /> ■ - White Co W M Yellow Copy Operator Pink Copy.LFA ■ <br />