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Waste Tire Survey& Inspection Report Inspection Report Number <br /> State of California I <br /> CMB1.'(New04,04) Survey Form - Page.1. 1 - 1088243 <br /> Califomla InteIWgrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 51 ( 1713 JZ Q O Routine O Re-inspection O Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 54h ?o aqutln C D ur+i y O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> �D_es+gqn Wood_1.�erk�h_ I _ <br /> Physical AddreVs � 3 q ' cT) j I <br /> L6�rj5j"t_Clr1 LuCgS-1 <br /> I-709 N—S_acr_owner+to St• <br /> Street Inspection Date <br /> —LO.d.1 C'AQ52'-`4�J Time In Time Out <br /> City State LIP Code <br /> Business Rep Title O AMO AM <br /> 1 O PM '� O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE). (Fill one only) -(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active O Passenger O Generator O Outdoor- <br /> - p O Closed Q Altered <br /> PS Latitude 0 Inactive' O Truck <br /> O Hauler O Indoor <br /> A <br /> N/ <br /> Longitude Io O PlannedO OTR End-Use container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader .0 Dismantler O Tire Derived Fuel <br /> • O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I I <br /> -- I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -------------- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ion nsion <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of ViolatO Exte <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 114 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered.Waste Tire Haulers O Referred/C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> O O 1 Other: § <br /> Comments <br /> `, S1nt�'►_A���P4�C.'�_L-OfIi—�Q,�C�r_m2�'�+l s ache �' �_L�o.I ID-W.L_n9 W is YLo'�t�t <br /> �O tLC4�—S�OrC�O!f_1�51T�,_.�0.G1,\_��May—p_k—MQt►_ACL �TY_eY'�l L 0 <br /> I, �t�ces—fir�eoY •_F�c:ili��w�4n�1.�_sz�s,�1J tt�s_(?aal s on-siva._. <br /> 1e�or .endo—iaac.�'�va e.T P_LD t 5�1.7�Z-01 . <br /> Inspection Form Included:O <br /> Comments Included:Q - -' — ' � <br /> Business Rep Ignature Phone Number I or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKncorre <br /> C reet:� ct: M 0 1 XIAIMIPILIEI 111,2131 <br /> 1111 <br /> ■ White Co .CIWM Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> • <br />