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i. 092100SO017 <br /> t € Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee_ <br /> �r State of California S u rve Form - Pa e 1 I 71 - 1086924 <br /> CIWMB 181(New 64104) y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (' 1 l , 3 l ® Routine Q Re-inspection Q Referral O Observation <br /> Local _� I ' If Referral,choose referral type(Fill one) <br /> Identifier: . J (� CaTI�1 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> kc Cavvtn�e� 13 - 1101 ( ILAL6_1_�11A.Iklba�, ,Ph ical Address <br /> LaQoqo <br /> Street <br /> 1 G J Inspection Date <br /> Time In Time Out <br /> City ` � State LIP Cods <br /> Business Rep Title � , Q AM l —� Q AM <br /> I ! IJ ' I—O �� <br /> 4D PM <br /> i l� ' CI�I PM <br /> m1ry�.e-&- C> L h � L_k t. `_Sa Operational Status Tire Type . Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) ,(Fill all that apply) (Fill all that apply) <br /> f f O Active O Passenger ®Generator Q Outdoor <br /> O • Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> . 0 O Inactive Q Truck <br /> Longitude — O Planned O OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder ®Other L_f�r K <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> RIM HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 I C^IWMB 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 Q 1 Other: §` <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: 111111 —� �� <br /> Business Rep's Signature i Phone Number In eco S' ure Phone Number <br /> INSTRUCTIONS ON BACK Co ect: correct: 33 <br /> AA X A P :L 1 2 3 62081 <br /> White Cop Yellow Copy.Operator Pink Copy LEA <br />