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0918250016 <br /> I:er. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> r� State of California <br /> CIWMB1811st(Now Manage) Survey Form - Page 1 - 1 2 - 1 0 7 9 3 5 7 <br /> California Integrated Waste Management Board <br /> 'art A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I J Inspection Type (Fill one) <br /> Site SufU a_T l l q u1 Routine QRe-insp <br /> ection QReferralTPID- p <br /> Q Observation <br /> Local r--' \ If Referral,choose referral type(Fill one) <br /> Identifier: 5001 J Od,Q �,�1 n W� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name b Inspected By Inspector <br /> IT.R �_o ' �3 � <br /> Physical Address 11 I 1 10 I I —fin-Esso <br /> Street / Loig] <br /> _La� r0 �� � Inspection Date 1a II„ 1 0 15 1 City 1— p State`�� Z1P Code Time In `(J Time Out <br /> Business Rep Title 10 <br /> 0 Am <br /> * PM I I� ' I d�1 � 1 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' ®Active Q Passenger ®Generator A Outdoor <br /> Latitude I I Q Closed Q Altered <br /> GPS I I I <br /> -- `-_=--_� - `- �-- 1_11 o Q Inactive ®Truck Q Hauler Q Indoor <br /> Longitude 1 l1-J. L_ Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder IS Other <br /> Part B -.Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 11 <br /> V A HAULING AND MANIFEST REC•IUIREMENiTrS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance 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 EXT) <br /> Q o 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/CIWMB Enforcement <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 /> —�C.�(_►�.s._ (_Z__lam" 5-`1 -- �Q.St�o-�--� k��c�,u -- <br /> l y <br /> o�v4��a���—o civ► _I11-1- ��_ i,��r_�� <br /> �L�r� on Sates 'fro r � Te�uhf S <br /> J <br /> Inspection Form Included: 10 <br /> N/Comments Included: IgnatureBRp/ e Phone Number _nspec f'_ Phone Num <br /> ber <br /> XMsP 4 L _ 62081 <br /> INSTRUCTIONS ON BACK coIEIIA Err <br /> I 1 12131 <br /> White Co y:CIW Yellow Copy:Operator Pink Copy.LEA <br />