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Waste Tire Su&y & Inspection Reporioinspection Report Number <br /> State of California <br /> aria CIWMB 181 teManage) Survey Form - Page 1 I1 - 1088145 <br /> California Integrated Waste Management Board <br /> Part ASurvey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details <br /> TPID- ' I O Q O Inspection Type (Fill one) <br /> Site Suffix: ] - <br /> LLI c� TI 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t <br /> Identifier: CAy) 70 U q 01'0 C OIf Referral,choose referral type(Fill one) <br /> urlt <br /> y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> a n e- i J 9 - � d <br /> Physical Address K r i S'}I on L u C as <br /> 27 Mar' c;asa Rd . <br /> Street , <br /> l _ 0 Inspection Date OT-7 / F" 0 <br /> Ck�o CA / Q <br /> Sio 5 <br /> I_ r' ?. Srate� ZIP Code I Time in Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Se E r• O PM O PM <br /> htrl _�..�'�d1n�Q�� i C <br /> 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 /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indod <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 /> n <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other I- eC�V t it t 1� - nt�►i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> cwt�n5_�eCton r afrn•e_ 1��s dC, _ -fie �c�IlowL� ��� r)0-�ecl <br /> G(_%\ ' uses Uel so � ��� Q o or Waste +\ye r-enoVol ADZ <br /> mnr��ests IncaP_ beer) fe-haIC1 u.)eQ C1Va\1ULle � IIN A,(_Or) Y_W�, . <br /> No or Gras �1 c_onCer 1L <br /> Inspection Form Included: <br /> "7 <br /> Comments Included: - "l_ Ztic . _ w_ <br /> r'^ <br /> C'Business 12 Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X A M R L 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br />