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08157040123 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> '° crWM811(NoCalftnnla Survey Form - Page 1 1 1 - 1 Q 7 9 2 Q 8 <br /> (.IY11*181(New 0410d) y <br /> California 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 g 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S1� "r-,-,.a �� 0 CHP Q CIWMB '0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ,JJ <br /> / <br /> Inspected By Inspector <br /> �I�AM�02A_P/_oPA <br /> Physical Addr ss n <br /> L7'A'ct f f-�,4,,�Er✓ I <br /> --- <br /> � !Street64 D / <br /> Inspection Date � / D <br /> ZO� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> O PM 0 PM <br /> IT-] <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 /> 0 Active 0 Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude I I 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude IF —I- -�I 0 Planned 0 OTR 0 End-Use 0 Container <br /> I-- J . 111 JJJ <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment . 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 /> 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 i 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 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 •In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments - <br /> D�75Grl rdel fivs�0£e ►�^!G•� r, ie; %��>�o%�o ' liiLy _ <br /> � _r�.4.s.1�f�:_kli%S�i—�✓�ay S.c.� �,.,o �,c TP.T� dk <br /> _�,_ls_�•iu-/i'_ <br /> 1 <br /> 4�<Lwlr�c%!i .t'6�do�tG_ . t this_-—– — •rs. tib <br /> via(4 <br /> Inspection Form Included:0� <br /> Comments Included:0 rp-is7Business R nature None Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect:X(J� CEJ E X A MIPILIE1 1112131 <br /> 62081 <br /> ■ White opy CIW B Yellow Copy Operator Pink Copy LEA ® ■ <br /> ) <br />