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07334040057 <br /> Waste Tire Survey & Inspection Report inspection ReportN!r r _ <br /> cr7r State of California <br /> ,r CIWMB181(New04104) Survey Form - Page 1 1 6 - 10 7 3 4_9_6_ <br /> Ca;jo Integrated Waste Management Board - - <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: <br /> [/__110 Q am/ 1 0 -yJ 9-L_J0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> --- - -- - <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: '�pc�gv� I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> P7J_Physical Address- / O_L_� L/17�lEWL�lL._� t1Tit�- <br /> G Inspection DateI I I I I / 1,; / Fo- <br /> C;!a t ZlPC6rjF' Time In Time Out <br /> Business Rep Title - j• —, O AM I-- i --i- O AM <br /> S PM I SPM <br /> ----'� - . <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (J (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active 0 Passenger 0 Generator 0 Outdoor <br /> --- — - O <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> ..._ O 0Inactive 0 Truck <br /> Longitude - j 0 Planned 0 OTR 0 End-Use 0 Container <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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 O <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 Date 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 EXT) <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 <br /> ®In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> --•� --- inS(�•#�—.3 c�k�4=t w�ts_2R_ s�---l.�Sc�►r_u_•�G'TL/_�t�T_s_. <br /> _�/htY v��tnrncc.S�n—Sl-tu1e,L�J'�—rnceal�c�,uev'Lee�Gyt�,_��el,L�+S_!�/v_C����t_t�er,�-ef_. <br /> —%res r�..u.—�u.�er.��ly l� Lau_,�cEG_'_ _9or Lstl�a rrti'�• h//�,�-.ilk=L. <br /> Inspection Form Included:0 <br /> Comments Included:0-- �` �� t8 O.6 Z3 <br /> Business Rep's Signature Phone Number. -tinspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'Io X A M P L ��1T� 62081 <br /> l�J <br /> ■ While Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> u - <br />