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;,A Waste Tire SL&y & Inspection Reporelnspection Report Number <br /> State CIWMB California 11 - 10 8 812 5 <br /> u ifornij grated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileIgk� Inspection Details <br /> -AM A911111W <br /> TPID- y Inspection Type (Fill one) <br /> Site Suffix: i! I I 3 _ ly 1 U it Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sart ToctgLAm C_oLj +t1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> W I rte Qar Uy P 13 [ I p J <br /> Physical Address ( I(r/_�I QI) Lu C i; <br /> i 1 7 0 00 E-. H,,,j ka I Z6 I <br /> Street <br /> Inspection Date V <br /> k. -a'n GA (IJ3G <br /> r f�, I State Z/P Code Time In Time Out <br /> Business Rep TitleI I I J O AM 0 AM <br /> 1--1f. Oft LLWarehuu� W 0 PM 0 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 /> e Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor� /Q 0 Inactive 0 Truck N/A <br /> 0 Planned OTR <br /> Longitude — I I I 0 End-Use 0 Container <br /> 0 <br /> Business Type (Fill all that apply) <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 e Other <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 0 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 <br /> M / M / m <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 /> 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 /> 0 0 Other: § <br /> Comments (ZUu� LtI Vh <br /> - -r t u r rn.e� �'1�t_ r�ct te-_�- _ +Iruz, _ o I l rj k.►I r)o t u o l rl_a{ <br /> F�,c��� _ t<� 5 4 Gl c c►�erI,t - n Nor_ SOAVE � _-�►t_� f41ce <br /> YerNo\/(I �-�Cl_ rncanse5ts Verve b4CCn reAQII)i'r� $ wEa <br /> C' C dyal\ bler <br /> ori f e�u2.s'� to, \4101 0A\' -j nz Wr car�0S. A COnCCI.0AV <br /> Inspection Form Included: 0 — f <br /> I <br /> Comments Included: 0 Business ��. <br /> Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> / <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �i V X ,Nt P', L I f 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />