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07312040451 <br /> L ; Waste Tire Survey & Inspection Report. Inspection Report Number <br /> r; CIW1.MB 81(Nmle SurveyForm --Page '1 1 8 - 1 0 7 3 5 2 2 <br /> GWMB 781 stew edlod) <br /> Callfomla Integrated Waste Management Board - <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / I I I 7- 1 411s I - a Inspection Type (Fill one) <br /> Site Suffix: Il 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> I Lrx.#s.rap Au+,,,. <br /> Physical Address I IrutMClAPff taw I <br /> 16.8 <br /> Street <br /> s33o Inspection Date <br /> Gj <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> Q ��AANNryryGG''�. m <br /> MOPM O PM <br /> Operational Status 'Tire Type Business Role. .Storage Type <br /> I (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> r I ®Active •Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude -� I,1-- - I I � Q Hauler Q Indoor <br /> _ J ill__ _- LLL___111___J�� Q Inactive 0 Truck <br /> I I V <br /> Longitude _ F7I -1 I_ I J I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer ®Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other t <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANrracat.t nc_tJIREMEN' Q Notice Of violation 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 Ue dline <br /> 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 equired IorNOV orFX7J <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/C-IWMB 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 S In C-ompliance - No viola ions <br /> Q Q Other: §, <br /> Comments <br /> /�Gl�-fint,-DtZS/XG�:�—QY_�fl�,_'S-G�r.�- f'LcL�l2icy Gljt-r h�-Li—�i2 <br /> - <br /> I <br /> Inspection Form Included:Q J <br /> Comme ` <��)-1006 <br /> Busmess <br /> Re s nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orree Ao ect j6j; V I E IXI AIMI P I L I EI 1 I'2I 3 62081 <br /> ffiQW <br /> ■ White C"CNVM Yellow Copy.Operator Pink Copy LFA ® ■ <br />