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08052040007 <br /> Waste Tire Survey:&. Inspection Report Inspection Report Number � <br /> CY State of California Q ►'y� <br /> CNJMB 181stew Odloe Survey For/1.1 - Page .1� 1 4 - 1 0 7 3 3 5 3 <br /> California Integratetl Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile. Inspection Details <br /> TPID- ' 1 19 I J [jZ_ <br /> Inspection Type (Fill-one)Site Suffix: I S *Routine - 0 Re-inspection 0 Referral 0 Observation <br /> I <br /> Local f Referral,choose referral type(Fill one). <br /> Identifier: Aw'J,��.VI __ t�CHP 0 CIWMB 0 Complaint O.Educational Visit 0 Other <br /> Business or Facility Name Inspected By <br /> Inspector <br /> Physical Address • [K�] F(I F/ I L_ <br /> (0`t•S W , Cham ►�a-�1 � <br /> Street ckC4U <br /> (� I Inspection Date / 8 <br /> City v State ZIP Code I Ims In Time Out. <br /> Business Rep Title /J1r0 Am 0 Am <br /> I � Cty �t [T] 0 PM <br /> EEI 0 PM <br /> 1 r <br /> DOperational 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) I' <br /> _. (D Active 0 Passenger 0 Generator 0 Outdoor <br /> O Closed 0 Altered <br /> LatitudeLl <br /> G 1. 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> - --tJ <br /> i <br /> Business Type (Fill all that apply). <br /> 0 New Tire Dealer 0 Auto Repair 0•Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A EMMANOURN1F77,Tr,EQUIREMENTS <br /> Violation <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments 'Oak <br /> a�5 4 FaciUjt, <br /> h oW�i%S an <br /> hanie, , Neco I rn_ss is J9 r&n_o 'es and no --Q <br /> Inspection Form.Included:0 L' �R <br /> Comments Included:0 16-� <br /> us' ess Rep's Signa ure Phone Number Inspector ignature Phone Number <br /> INSTRUCTIONS ON BA Correct: Incorrect: f= X A P 1~1E11 111[213 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />