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' Og1� �609�469 <br /> lee_ <br /> Waste Tire Suay & Inspection. Repo Inspection Report Number <br /> CIWMBCalifornia 04/04) SurveyForm - Page 1 Il - 1108444 <br /> California Integrated Waste Management Board . <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile -Inspection Details <br /> TPID- i Z I Inspection Type (Fill one) <br /> Site Suffix: L1 I I I I V I ► ,� I - I O I l ® Routine o Re-inspection o Referral <br /> Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> aIdentifier: In JCao-IV\ � n � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 1 <br /> n�n� �1_._Lau�So)_1— K;_O_. L- , 13 `� - I /PhjscaI Address <br /> L1_OS_q S <br /> Street <br /> ,/r Inspection Date <br /> LIQ rP__Y) 7 <br /> OY State <br /> -tate Ll0 Coo' <br /> Time In Time Out <br /> , <br /> Business Rep C l^ l Title tp O AM I / I -__ Q AM <br /> 40 PM <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 /> f ' _ ®Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> i Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility STATUS <br /> I VMA�HA-UL■INGIAND�MANIFESMiI3EQ.UIREMENTS <br /> Q Notice Of 1/iolation Q Extension <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 <br /> Qo 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q o 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!GIWMB Enforcement <br /> Q o 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 /> 0 o Other: §`--- - - -{� <br /> Comments "1o '`n�_—As PA��Qa& en <br /> O 1/I�LO .� o y 'c 0f Kca�_C_e_✓� <br /> Inspection Form Included: <br /> i�3trs_i <br /> Comments Included: �ness iC- <br /> ep's-signat re Phone Number I pe ors S' na re Phone Number <br /> E I I 1112131 <br /> 62081 . <br /> INSTRUCTIONS ON BACK rrect: correct: X A Ah P L E <br /> White C py.CI Yellow Copy.Operator Pink Copy.LEA <br />