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09049040016 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ rii' ■ <br /> $sloe1omia SI1 <br /> LIWMB 18181((Naw ONed) <br /> Cailfomia Integnted Waste Managemurve�/ Form - Page 1 1088266ent Board J <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 I I 3 1 l 0 19 1 _ D Inspection Type (Fill one) <br /> Site Suffix: ` I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: I k0 Jo0.j Ul1) lCoat4n I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> i4;n (x, <br /> Physical Adc.ess Flood Chc�nne� C1ii,nEenan« 3 q _ 0 I) I ( n fstn <br /> I NO £. 6 &oo Am, � <br /> StreetCL I <br /> Inspection Date_3T0_MV0 15 Y <br /> City State ZIP Code Time In Time Out <br /> Business Rep <br /> ! Title 0 10 AM I I O O 14 AM <br /> OPM <br /> 0 PM <br /> i - <br /> 6 rational 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 I r 41 Active 19 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 49 Altered <br /> GPS Latitude J— -_` 0 Hauler 0 indoor <br /> _-0 0 inactive 0 Truck <br /> Lon nude <br /> 9 I ! I.� I i I 0 Planned A OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet •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 /> 0 Service Station ®Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility crria6r9cA ENT STATUS <br /> rY A 'HAU-LINM1nic1YJIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance lka line <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 or 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 Refe red 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 Yioiat(ons <br /> 0 0 Other: § — <br /> comments t <br /> 12b_u,4►nc._�n5pec�tr.,'�lc�o�e,_o1n-��1t5 - I�ndl--��o�lbuf� wccs 1-4rf-,�e� <br /> —51-j IRS ��- P <br /> � I —c +o ove,�ei to �1c� Vra�4�rno5 <br /> ` _r-�,���l: <br /> Inspection Form Included:0 <br /> Comments <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> ■ INSTRUCTIONS ON BACKCorrect:�Incorrecte I E IXJ A IMI P I L I El 1112131 62081 <br /> White Copy CIWM8 Yellow Copy.Operator Pink Copy.LEA ® ■ <br />