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l <br /> 08325040075 <br /> cnn- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> elatma a,lNo* Survey Form Page 1 � I 1 __1_088210 <br /> -1 <br /> CIWM81B1 INew W/eC) <br /> ceilfomla Integrated Waste Management Boats <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i I —i i Inspection Type (Fill one) <br /> Site Suffix: I 51 1_ 1 Cr 11 8 - I �1 i 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I T t4in `,OUni If Referral,choose referral type(Fill one) <br /> Oqq i y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: 5 c <br /> Business or Facility Name <br /> Inspected By Inspector <br /> IC( <br /> - I <br /> Physical Ad�ress ( O <br /> ISrreet8.00---W.--GhurCAk st -- --I - ; --, <br /> Inspection Date <br /> Statr Z;1 Time In Time Out ------ <br /> t'r - <br /> Business Rep Title - — --- — O AM r— - ' AM <br /> O PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - 0 End-Use Q Container <br /> 0 Planned 0 OTR <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 —;=,bey- tZ2c, <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> 0 0 <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 Data m /m / m <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 FXn <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 10 1 Other. § <br /> Comments <br /> No��res obs_etved�b.e_s}occd—on-sib.Sit n on_:�ac,ilt_i-y ron <br /> d(SO s tx es /]� —03rin _9g_3. <br /> cel-oCq t:.d o U_Qc Z.007 f'o <br /> _Z157 fsralnd Cat\gl $V�_si-e. 202.i-5�oclr4on CA 9`-��� •�hJS �at:�i <br /> { �sslosed.�' +b;a 1xs��io±n_.Recomt�end to c.��e. T_P_l.p � IS19982.-01_.— <br /> Inspection Form Included:0 ./209) <br /> Comments Included:Q ��ed0 _ — y3UB <br /> Business Rep's Signature Phone Number Insp s S gnature Pho a Number <br /> INSTRUCTIONS ON BACK Cor ect: I correct:%Q(�V qf XIAI]MIPILIEI 11 Z 3 62081 <br /> ■ White Cop CIW Yellow Copy Operator Pink Copy.LFA ® ■ <br /> l <br />