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ttE„ 1 ' <br /> %*nspection Report NumberWaste Tire Su"y & Ins ection Re or <br /> - <br /> "' CIWMB California <br /> Survey Form - Page 1 Il 1088038 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � LA <br /> `A� I l � � _ O Inspection Type (Fill one) <br /> Site Suffix: ( 40 Routine Q Re-inspection Q Referral Q Observation <br /> Localr- u" If Referral,choose referral type(Fill one) <br /> Identifier: Sco JO" n Ukk44 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> lI <br /> Physical Address <br /> a1135 E. Qs Ave . - <br /> �.�' n Inspection Date <br /> O[ <br /> " �`G \ {v `� Time In Time Out <br /> Business Rep Title � � O AM 0 AM <br /> � PM <br /> 1 O 0 PM <br /> RkG� P o ` Cen�w� m v <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) {Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � b <br /> ' 0 Active Passenger * Generator * Outdoor <br /> O Q Closed �Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 Other T[��S�ef '(,i,}>�Q� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT ST U <br /> Q Q Q Notice Of Violation Q Extenslo <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m LE] <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) '~ <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Q Referred/CIWMB .Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities E -__ .-- <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q In Compliance No Violations <br /> Q Q Other: § <br /> Commentso „ .L;nsp )2�� 1�2t - <br /> Ce <br /> Inspection Form Included: _6O`\ ` l <br /> Comments Included: lsine,,Rep's Signature Phone Number Inspector's Signature _ Phone Number <br /> _ -- L 62081 - <br /> INSTRUCTIONS ON BACK Correct 'incorrect', l P A f 2 3 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />