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07319040162 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sto wMB 181CaliforniaNSurve Form - Page 1 . 1 3 - 10 7 3 5 8 3 <br /> CM/MB 181 t ew OUee). Y <br /> Celifomia Integrated Waste Management Board . <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> + TPID- - Inspection Type (Fill one) <br /> Site Suffix: 5 ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Cmtrn �a- Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name Inspected By Inspector <br /> I Nor"' , 6 N1A�Physical Address Liil F/ t7 <br /> LA <br /> I (e 2.50 �SC4.Qd11.—l�lj0+� I <br /> Street <br /> Inspection Date <br /> L,��•- CA <br /> I9s� <br /> City State ZIP Code Code Time In Time Out <br /> Business Rep Title m:MS PAM M m;m ®AM <br /> PM <br /> i -_�IxY1_ -JLr2lMC. iIV1 i _ __ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i ( r ! I ,,( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5lJ ®Active Q Passenger ®Generator ®Outdoor <br /> Latitude I I I �1�W 0 Q Closed Q Altered <br /> GPS I I I Q Hauler Q Indoor <br /> — 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) IJ111�����11 <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 <br /> Part B-Inspection of Waste Tire Dealer,.Generator,Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V A HAULING 19 MANIFEST REQUIREMENTS <br /> 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 /> Q Q 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 Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for NOV or EXT) <br /> Q Q 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> —kts—uccdLW_i-IcIn1,­Mem.—ED�s aa�o�tYuco.c�r v_1w�c.l—�c.l _ <br /> Inspection Form Included:QI � <br /> -nff-- �6T'oz3 <br /> Comments Included:Q /'�-- �� <br /> Business Rep's Signature Phone Number -T 6 pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Ah X .� P ;L E 1 '2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy LEA <br /> I <br />