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VOA Zi?til°iQ V.A.7 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number . <br /> Stale°`Cal''°`°'a Survey Form - Page 1 1 8 - 1 0 7 2 8 1 3 <br /> CIWMB 181 IN—04/04) <br /> calirpmle Integrated waste Management Board <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type (Fill one) <br /> Site Sufflx: �. <br /> f, O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Q CHP Q CIWMB Q Complaint Q Educational Visit Q-Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address mo / � <br /> StSt e�D 2 S1, ST0C_L4ar ST <br /> C/n" r� Inspection Date <br /> City <br /> i � � State ZIP CodJ 'eJ Time In II Time Out <br /> Business Rep Title O AM <br /> O AM <br /> / 0 P m'm OPM <br /> Lys Al C't✓ji No_ �•4 rtGiA �t_�---.P `l5 _. --- <br /> Operational Status Tire Type Business Role •Storage Type <br /> i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) .(Fill all that apply) (Fili all that apply) <br /> '�� I I� e i5 <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude L�•I I 'I Q Hauler Q Indoor <br /> ((!!-- O Q Inactive •Truck <br /> MLongitude – 1I .LL l l� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 OtherLe— <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFaORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q E enslon <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> -- <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Oeadfine <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 <br /> (Required for NOV or EXE <br /> 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 Referred I 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 ®I In Compliance - No Violations <br /> Q Q 1 Other: §, C <br /> Comments <br /> �7yl.ertiV� inls,ioe�t i�- i• <br /> I^ %5 �.�t� 1-�,'�tc �a;�i,G A,.4nh'~C2..SAS VI'-')-_A /Vo V"n 6 dib,3 <br /> Inspection Form Included: Q <br /> Comments Included:Q <br /> Business Rep's Signature one Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK Corrects Incorrect: f: X A M PILIE1 1 Z 62081 3 ® ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> I <br />