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��z1o04051L <br /> L119 <br /> Waste Tire Sui&y & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB (New 04(04) Survey Form - Page -1 I 1 - 10869 14 <br /> Califomia Integrated 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: Li 3 I S, �0 =ZI--J <br /> I*Routine Q Re-inspection Q Referral Q Observation <br /> Local �" 1 If Referral,choose referral type(Fill one) <br /> Identifier:- _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> °_L00% ' 3 <br /> PF�iyslcal�dd ess I jod] <br /> L-v 3-N a. -Ln. I <br /> StreetA1_0 l J ���-1 Inspection Date <br /> city State ZIP Cc Time In Time OutyV 11 <br /> Business Rep Title I �I-�� AM IhI IO_ O t� AM <br /> rl �QjV1CP.�S ` I I ) � Il 0 P ---l� ' � . � QPM <br /> Operational Status Tire Type Business Role Storage <br /> P YP 9 Type <br /> Tire Count(Whole/PTE) ' Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f I ®Active 9 Passenger Generator ® Outdoor <br /> ! Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive -® Truck <br /> Longitude - j Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet jo 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 Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V A HAULING ON MANIFEST REQUIREMENTS Q Notice Of Violation Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I GI Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliancA - No Violations <br /> Q Q Other: § <br /> Comments w (Vfn-)�� <br /> Inspection Form Included: <br /> Comments Included: <br /> 2Q nTc/one Nu'm4�b�er = Inspe rs S — � <br /> Si naturPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ct: neorrect: K A M P LIEI, 111213 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />