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07313040177 <br /> Waste Tire Survey & Inspection ReportInspection Report Number <br /> ) <br /> StateofCalifornia <br /> 94/0Survey Form <br /> CIWMB -- Page 1 _ I I 8 - 10 7 3 5 8 3 <br /> 191(New <br /> California Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection�/ I O I Inspection Type (Fill one) <br /> Site Suffix: l 5 I d I .2 I T I oZ I - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 111 1t If Referral,choose referral type(Fill one) <br /> Identifier: f Sysh TOctcn,u,yy Cs—,*` I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C4 (� — <br /> N � U, S�, <br /> (Physical Address I I 3 I I I U l+�►ytu�tt_ v+tY,,. <br /> Street <br /> Inspection Date <br /> CA 9y-z yo I <br /> ICity State Zip Code Time In Time Out <br /> Business Rep Title O AMQ AM <br /> lit iY C lcicfi Or wyu�Y :m®PM W'm ®PM <br /> Operational Status Tire Type Business Rale Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I j IO <br /> 40 Active Q Passenger ®Generator ®Outdoor <br /> (I O Q Closed Q Altered . <br /> GPS Latitude �: Q Hauler Q Indoor <br /> lll����LL��JII Q Inactive Q Truck <br /> V <br /> Longitude - 111 <br /> I ], I I Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) ATV/17i Ali w <br /> Q New Tire Dealer ®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 Q Other LM,q,,r„'r p A-r V <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility I ENFORCEMEN -- <br /> T STATUI'S <br /> V"H'AULINGtANU MANIFEST REOUIREMENTeS <br /> Q Q Q Notice Of Violation Q 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 Date m / m m <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(or NOV or EYTJ <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 1 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 Ylolations <br /> Q Q Other: §, <br /> Comments y-t+ - t 2e�S ia4�53�-83 d 3 e.eInspection Form Included:Q. <br /> Comments Included:Q xI <br /> r f{t.0-0629 <br /> Business L's Signature Phone Number Inspector's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Gorlect:� Incorrect: IfIXIAIMIPILIEL I1F2I31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:-Operator Pink Copy:LEA ■ <br />