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07312040432 <br /> Waste Tire Survey & Inspection ReportState Inspection Report Number ■ <br /> C1WMf161(Nrnla Survey Form - Page 1 .� 17 - 1 Q 7 3 5 5 4 <br /> Cgrated 1sNew nage <br /> Califomla integrated <br /> Waste Management Board <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Sutrix: I '� 13 Q I p I.3 6 1 3 ®Routine Q'Re-inspection Q Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U_ r.1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector. <br /> Physical Address � O L �pGrh�V"� <br /> I Street 10.3-OO <br /> 1 Inspection Date O G 1 O O <br /> city �t.{�—LdMn-A Cf ZIP C J / 1 6 <br /> City 1 S�ta ZIP Code Time In Time Out <br /> Business Rep Title Q AM O AM <br /> _- <br /> W1111111,PM �'m ®PM <br /> _f aA�_ [�rvuxw^ L C�Y" Q �_ Operational Status .TireType Business Role Storage Type <br /> Tire Count(Whole/PTE) l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Latitude Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> III111 <br /> Longitude — I— 1 I---f I �I I I 1 Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) I <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 A Other �Ce�rsinec.l��ix l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler.and End-Use Facility t��rl•I �i _ uST1ATUS <br /> IrVEEAssagHAULING,ANDIMANIF.ESITLREQUIRf_MENjt$ <br /> Q Q Q Notice Of Violation n Extension <br /> 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 (Required for NOV or EXTJ <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/CIWMBEnforcement <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 Compliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> Li�/SQo_�un9u,h�Cars�'b_fi_�nzr�'PLD .boo_51-0%s_�:ssucnL_zr_,olt.. h�-••cs <br /> �/ h- i 36$363—a/ in:v %c/ ced�Lrcrr_ cv»+�+l�f c�o.s±A,t <br /> Inspection Form Included:Q t ) 341 <br /> Comments Included:Q k 17,q VN /Btt S/6A-8623 <br /> Busines Rep's i r Phone Number Inspector's Signature Phone Number <br /> I N111.2131 62081 <br /> ncorrect: dh <br /> INSTRUCTIONS ON BACK rrect' X A P L E <br /> . White IW Yellow Copy.Operator Pink Copy.LEA ■ <br /> r <br />