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08129Q41093 <br /> Waste Tire Survey & Inspection Report Inspection Report amber <br /> r� state of Califomla <br /> CIWMe,st,Ne-,19 Survey Form - Page 1 1 1 - 1 .Q 7.9:.1 4-'1 <br /> Califomla Integrated WaaN Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID 0 ' Inspection Type (Fill one) <br /> Site Suffix: 1 /T000�`� I � - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local !_ �x If Referral,choose referral type(Fill one) <br /> Identifier: r/!�]-�/f` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector o <br /> Physical Address - 1 13 9 ! 0 LTA�Y�Li <br /> S$$ E. Lv1c� 5f. — <br /> Street <br /> y 04 95�T� I Inspection Date U� <br /> city (f (fU State ZIP Code Time In Time Out <br /> Business Rep Title m'm 0 PM m.F Q PM ' <br /> — - --- -J Operational Status Tire Type Buslness'Rola Storage Type <br /> ! l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) ' <br /> Tire Count(Whole/PTE) I (] <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> j - O Q Closed Q Altered <br /> GPS Latitude I 1 ! I Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude Q Planned Q OTR <br /> - <br /> End-Use Q Container, <br /> I� I III <br /> Business <br /> 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other I— <br /> V <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS y <br /> A I I .,AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> _s <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 <br /> Q Q __.. ...._... . - t <br /> 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 I 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 C-ompliance - No Violations `.' <br /> Q Q Other: § / y <br /> Comments �� /�.S�G h0 •eS /(/� �l j lf2�J ..i s 145.� <br /> Inspection Forrn Included:Q <br /> y60-0 7q <br /> Comments Included:Q r <br /> Business Reps Signature Phone Number Inspector's gna ure Phone NumbeF <br /> 62081. j <br /> INSTRUCTIONS ON BACK Cor act. I correct: X A M P Q 1 2131 <br /> 3 <br /> - t <br /> . White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® 'YF• <br />