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V O L L V 5 V V L V <br /> ata. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State atn C1WM 181(CalffOma Survey Form - Page 1 I1 1088126 . <br /> CIWMB 18t(New nage. Y <br /> Callfomla Integrated Waste Management eoanl <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- 1 n =Q1 <br /> Inspection Type (Fill one) <br /> Site Suffix: C� 1 t'Routine Q Re-inspection Q Referral Q Observation <br /> Local S Qfl TOfI UIYI CO Ut If Referral,choose referral type(Fill one) <br /> Identifier: 9 y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Y <br /> Business or Facility Name Inspected By Inspector <br /> L_Sfiock-4'an IV_issa►r1 5[q:1 <br /> _ 7_0171 <br /> Physical Address <br /> L_K_n_st�ar�_l..w_eas—I <br /> Street <br /> Inspection Date <br /> L_Stockfion GA 952iz <br /> City State Z/P Code Time In Time Out _ <br /> Business Rep Title —, I r i AM <br /> I . I I.i <br /> .I 1IMAM O 0 PM L__J 0 PM <br /> A u1_o�f __. Service. . M pr. <br /> r 9 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -77 (Fill-one only) (Fill all that.apply) (Fill all that apply) (Fill all that apply) <br /> t 0 Active 0 Passenger 40 Generator Q Outdoor <br /> Latitude � <br /> 0 Q Closed Q Altered <br /> GPS Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer' 0 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility ENFORCEMENT STATUS <br /> Q Notice Of Violation Q Extension <br /> V A HAULING ANfD MANIFEST REQUIREMENTS <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 pate m / m <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 DCT) <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 O In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> 9Zout'►.na.—tnsPect►on�a.r_rnr�red—th�s__dc'�'e 1�e win 7-0- n_o*ad: <br /> FAC��i��_w5es u kx5lbe R"o_,feX�—W.C�S+ �t�q —4-�h2.—1 enf 0-! Q�d ho_u��,vCr _ <br /> -tk�,�asil.,}�his not h� ncnu�wasl��r-i-Y�s�c�oYec�as oS'�iis <br /> No <br /> Inspection Form Included: G�•(__ a� <br /> Comments Inclu000, <br /> ded: — — – -- – <br /> Bus n s Rep' na re Phone Number In s Signature _ Phone Number <br /> YA 62081 <br /> INSTRUCTIONS ON BACK 6orrect�1 correct: X A M P 1 .2 3 <br /> ■ White hit-17 Yellow Copy.Operator Pink Copy:LEA - ® ■ <br /> I <br />