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07312040460 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> r cWM'fCalHomla Survey Form - Page 1 1 4 - 10 7 3 5 2 7 <br /> CIWMB 181(New Od104) <br /> califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 L Z - ' Inspection Type (Fill one) <br /> Site Suffix: 3 D 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier: �q0 CHP 0 CIWMB .0 Complaint 0 Educational Visit 0 Other. <br /> Business or Facility Name U Inspected By Inspector <br /> 52 - F/101/1 <br /> Street s��s , _Allad I <br /> Inspection Date <br /> I CA �ISZ/S <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �r �oo1c k cfc'r ®PM [IT 0 PM <br /> �_NiSlso In_._Laarr_eJs __ I t__otn[xc<Q-- I <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f I e <br /> •Active 0 Passenger •Generator 0 Outdoor <br /> Latitude 0 Closed 0 Altered <br /> APs LI_J-L-_1__1_ I 0 Hauler ® Indoor <br /> - -.— IO 0 Inactive0 Truck <br /> Longitude - FTf I,1 I- I� 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all thatapply) JJJ 111 <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 jP Other L_7— <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 �Extension <br /> 0 0 , 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 I]] <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€)CT) <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 0 Other: § <br /> Comments <br /> AS <br /> A/ <br /> —c�.�2Ls�s-2_�//to% y✓�, �/K ar_�Jk_,-t�—!_-u��- 'T/�//�D_T_ --- <br /> -%U/ <br /> Inspection Form Included:0 I0/U <br /> X <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAC Correct: Incorrect: 62081 <br /> � EXaMP .� E: 123 <br /> ■ W hit opy:CIW Yellow Copy Operator Pink Copy.LEA ■ <br />