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07312040406 <br /> CIB. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ . <br /> Stata of California <br /> CIWM618t(New 04104) Survey Form- Page 1 L2 - 10 7 3 3 3 5 <br /> orn <br /> califla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> +PID- ' 191 kD1 <br /> Inspection Type (Fill one) <br /> ffi131 ' <br /> Site Suffix: *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: j(XitQi((t}ti C �x,H CHP CIWMB Complaint'Tn�_ � / Q Q Q P 0.Educational Visit Q Other <br /> Business or Facility Name U V 1:yt Inspected By Inspector c1 ' <br /> G <br /> Physical Address <br /> I 13 10 hili ki`LW Pi St I - <br /> Street Lo J T / ' O / <br /> / CA ��- I C) InspectionDate (Wy1 U � D J� <br /> - <br /> ity % C/l State ZIP Code Time In Time Out <br /> Business Rep ,Title Q AM O AM <br /> 0 PM m0 PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> ( j I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I I O <br /> ctive Q Passenger Q Generator 0.Outdoor <br /> Latitude O b Closed Q Altered <br /> GPS '_1 Q Hauler Q Indoor <br /> I O `Inactive Q Truck <br /> Longitude Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) I J JJJ <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 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler-and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 0 Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 M / m / m <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 (Required for NOV or EXT) <br /> 0 Q ------ -- -- <br /> 14 CCR§10459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 ®In Compliance - No Violations <br /> 010 1 Other. § <br /> Comments d ,r1$ r r zs Tzt e l ; I/1s �01/ J D✓tV�1�� <br /> ►vl<zvti>CeSfa✓ai1 /no 6 V&'-dor _ <br /> -wli _ Zh�ty <br /> Inspection Form Included:Q ��� /7yyS� <br /> Comments Included:Q - — -h� , 1a'� <br /> es <br /> R p Signature Phone Number In ect is sl4_tar,-Z� <br /> 21 <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X& .Q E /L hh P E1 2 3 62081 <br /> . White Copy.CIWMB 'Yellow Copy Operator Pink Copy:LEA ® ■ <br /> l <br />