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Waste Tire Sl.*y & Inspection Repor ,, Inspection Report Number <br /> State of Survey Form - Page 1 t� $ <br /> CIWMBB1 Californiaa f New 04/04) ■ <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- �-` Inspection Type (Fill one) <br /> Site Suffix: V � c) 578 Q - t�J-1 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ars 7G Q L4m C,ou' _t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ALMS SSW s s«Ip k4 -- <br /> Physical Address ` 0. <br /> I V_Y Ct'n (..U['a_% j <br /> I <br /> 1'_L0'-1 E. M aox-) Stre-tet i - <br /> Street <br /> Inspection Date <br /> Sty c.kion LA g520-9 U <br /> City State ZIP Code Time In Time Out <br /> W <br /> 0 AM <br /> Business Rep Title (�(� . m 0 AM : m O PM O PM <br /> Operational Status . ire Typc Business Role Storage Type <br /> (Fill one only) '(Fill all that app (Fill all that apply) (Fill all that apply) <br /> Tire Count (WholelPTE) <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 /> L GWnrnU�JC-r 4;a,., <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® 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 /> 00 PRC§42951-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0Compliance - No Violations <br /> 0 0 Other: § n <br /> Comments <br /> ota-_ __Ar~u Utrrne,C� 1��. c� {Q g (A)12 S <br /> I c <br /> rp-rnGyla) YOM J�r(,r0l Clc� �r.G�= hc,d <br /> n,tic� C;T L ci�e os,f'l _ Qrl C P rn <br /> Inspection Form Included: <br /> Comments Included: 0 ' <br /> Business Rep's Signature Phone Number Inspector's Signatur- Phone Number <br /> INSTRUCTIONS ON BACK Correct:I& Incorrect: X A�, X IA M1PIL El 1112 — 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />