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0 <br /> C�JI V-1f L VL <br /> - Waste Tire Survey & Inspection Report ` Inspection Report Number <br /> N <br /> s CIWM.te181'(Npw Survey rve Form - Page 1 , Il 10 8 8 2 8 3 <br /> CIWMB 181(New 041sd)' �/ <br /> Cellfomla Integrated Waste Management Board J <br /> Part A-Surve ' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t - Q Inspection Type (Fill one) <br /> Site Suffix: � 41019 <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S ah Toa 9 ut n C O 111 1 F Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> i <br /> Business or Facility Name <br /> • Inspected By Inspector <br /> Physical Address <br /> LKt►Sti.an_Lu cgi_J <br /> L 2y20 E. E►g 4r} M►�e Rd. <br /> Street <br /> Inspection Date <br /> I—SA-o CJ,-+Or1 C}1 95 2101 <br /> City State Zlp Code' Time In Time Out <br /> Business Rep Title F-70AM [= <br /> O AM <br /> ' O PM O PM <br /> L__Mart.a-- 'fief- s J L duaT.W.tr - <br /> Operational Status Tire Type Business Role Storage Type <br /> j 7 (Fill one only). - (Fill all that apply)•(Fill all that apply) :(Fill all that apply) <br /> Tire Count(Whole/PTE) . r' <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> 'O QClosed QAltered <br /> GPS Latitude Q Hauler Q Indoor <br /> - - -'- -- -- Q Inactive 0 Truck <br /> Longitude - I I;,f i Q Planned Q.OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government p 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 FacilityENFORC^EMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Date�ReguilW@XIj 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 or F,C7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs fora years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers KQ 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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> — �fi�,a._ttns_p4cfiora��o�-fhss_dai�.��.�n-tlowi�t9 was n.at'ed_: <br /> Cit,�yse Ares—s'1'o�ed o+n-s►�e_ F0611+,'111} uAu McS_oy`S1r�tck <br /> Tr <br /> ie servrce. -tor �oz+e *6 reMoycnl_. EDT rncx1m3 l-s cxyaikable r <br /> V14.vJ� oft e�a�}t ons dr areas at co rtc e-r o- <br /> Inspection Form Included:Q <br /> Comments Included:Q Pko <br /> — - - <br /> A.i.j./gaps <br /> --Sig .tun Phone Number I or's Signature Phone Number <br /> INSTRUCTIONS ON BACjCopy: <br /> ct• nt orrect: X M P L E 1 2 3 62081 <br /> ■ WW 1 YellowCopy:Operator - Pink Copy:LEA - ® ■ <br />