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09049040013 <br /> era. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Stateorcailfemla Survey Form - Page 1 I1 1088346 <br /> ChVMB 181(New nage Y <br /> Cellfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �T^ M <br /> I rr S _ � I Inspection Type (Pili one) <br /> Site Suffix: I! ' 13 b ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 �� If Referral,choose referral type(Fill one) <br /> Identifier: Sgnlomqul n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By inspector <br /> t. <br /> e <br /> LL�kQ dreessss �n-mai r <br /> Physical Address <br /> i_aouk N��y <br /> Street <br /> Inspection Date <br /> L_S�o�ko� cA 9 5 ao� I <br /> City State 7_IP Ccee Time In --- -] Time Out <br /> Business Rep Title O AM ' n n O AM <br /> S 1d S PM -1 I' V I 10 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 /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude i 0 Hauler 0 Indoor <br /> - -- -_ - -= 0 0 Inactive 0 Truck <br /> Longitude - l I,I 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 iA 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 0 Other I 4 <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 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <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/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 /> I0 Other: § <br /> Comments �Oln2a �f�,pegn—CJw'tC•='^- 1_S—dCi1�QA_154_%, XS—nCTC1A <br /> ros a�s���a lt —�uci�i c. can_E_CS7 <br /> Inspection Form Included:0 r�t u t, <br /> Comments Included:0 -a�-�6y'/If� _ `aA-1_"6=i <br /> Business Rep's Signature Phone Number lnspe ors Signature Phone Number <br /> . INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1.'2 3 62081® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />