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08 87040003 <br /> Waste Tire ■ <br /> •roe. <br /> Survey. &.Inspection Report Inspection eport Number <br /> CIWMState B <br /> 181Iemid Survey.Form - Page 1 15 - 1 0 7 9. 1 8 6 <br /> CIWMB 181 stew nage <br /> 4104) <br /> Cali/omia Integrated Waste Management Board <br /> Part A-_Survey . BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection <br /> I 2 Q [ Inspection Type.(Fill one) <br /> Site Suffix: J 1 0 Routine Q Re-inspection. Q Referral Q Observation <br /> Local .San If Referral,choose referral type(Fill one) <br /> Identifier: SO4�t 11 T1 Cdex t� O CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I__COca- C.O CL Ca-H1kN CO.r_ct.�Clkn�� 3 9 _ l 0 <br /> Physical Address <br /> 9 II L ishan Lu�4s� <br /> Street <br /> Inspection Date. <br /> I S+ock�o�n Gh 95Zo-51 <br /> ity State ZIf-Loae Time In Time Out <br /> Business Rep Tide OAMELI O AM <br /> :F1 O PM O PM <br /> �O� (a u e rr ux i tR4d_M_ech_cm i-c,� Operational Status Tire Type Business.Role Storage Type . <br /> Tire Count(Whole/PTE) ! (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 40 Active Q Passenger 0 Generator Q Outdoor <br /> F <br /> O <br /> GPS Latitude T O Closed Q Altered Hauler 0 indoor <br /> I� O Q Inactive 0 Truck <br /> Longitude - 4 I I Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> J -- -- - —— <br /> p New Tire Dealer . O Auto Repair .0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body ..Q Car Dealer Q Collection . Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler.and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND.MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste-Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle _ <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m /m /m <br /> O O 14 CCR§18459.1.-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F"Xf) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years. <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance - No Violations <br /> O 1 O 1 Other §, <br /> Comments R Ott+l nQ �_nS- t i o rL_�_C OLMEC�- 15 �.0. <br /> �G %tj LA Z45 __Wtisoh (Wu��lre for-- has to—_ hCe_%0c1u\in3 —recce tri-9----EC T <br /> tAnUA"PQ feto,i nec) or___-!0M—_PQ24A0us 3. rs c,vo�1a�14--- o_r r_e.v�.tw_uQon <br /> i 0 1 <br /> _ S Y1 _ or r•�aS 4—c.V-(:,- <br /> Inspection Form Included:Q <br /> Comments Included:Q - 513- / 9ft45 i ess p's Signature- PhoneNumber In Phone Number <br /> INSTRUCTIONS AC or t: Incorrect: ® ■ <br /> hit tp <br /> Yellow Copy.Operator Pink Copy.LEA <br /> I - <br />