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=L„ Inspection Report Number <br /> Waste Tire Su ey & Inspection Report <br /> La State California Survey Form - Page 1 ( 6 - 1 0 l 1 9 5 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- jQ Inspection Type (Fill one) <br /> Site Suffix: 1 O Z (� 2 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localu If Referral,choose referral type(Fill one) <br /> C O Un 1 <br /> Y-\Identifier: San TO Ck �{LA � J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName Inspected By Inspector <br /> ave-4-es cid 3 q - 1 Q 1 .. <br /> Physical Address i�%'f 1�t%ark L(AC,C15 <br /> 55`j til . 0.\f 'it . <br /> Inspection Date <br /> t'1 Ck CA 915336 Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> 7Tire <br /> ount(Whole/PTE) 8 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � � <br /> 0 Active 0 Passenger *Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q End-Use Q Container <br /> Q Planned Q OTR <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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility r ENFORCEMENT STATU_S <br /> V � A <br /> HAULING AND MANIFEST REQUREME <br /> O Notice Of Violation OExtension <br /> 0 § Ir Registration and Transport of Tires <br /> Q 0 1 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 0 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 EXT) <br /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> — - ---------------- <br /> 0 <br /> ------ --- - - - <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> e In Compliance No Violations <br /> 0 0 Other: § <br /> Comments RorW.c1 —Nets c4c%7lre 4Z 401(o0)Ino COX- , <br /> nu-�'�r�. �nS�ec-k-►en a+?x-� ��___, ps�ec�a <br /> �aC,k1�t�. _tc(52S at' R,0-nn JE t11p s1 zr)c • ��r ui�,s-`i-e. r2 lncL to )0 <br /> mush �e Fn> o c vea5 concern no--'ea . <br /> Inspection Form Included: Q (2jq) <br /> Comments Included: Q — �2Q1. 3-L7 - <br /> Busine s Re 's Sign ture Phone Number p tor's Signat Phone Number <br /> INSTRUCTIONS ON BAC E_<X A` p L 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />