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- t <br /> 10041050014 <br /> Waste Tire Survey & Inspection Report - Inspection.ReportNumber <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page '1 I 1 - 11276.95 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> .Site Suffix: I S Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier; S(l n J �,n co Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Qcamon F 6A cr. f4oA)N(AN ML-01 —I—k] <br /> LL <br /> Physical Address - <br /> L-N- W-11500 W u,y-C <br /> Street 3990�� <br /> 95,10SInspection Date { ' [)!0] <br /> L 0e1 O\ 95 <br /> city State 7IP Code Time In 1 Time Out _) <br /> Business Rep Title L0 AM-L <br /> f0PM Ell • J 0 P <br /> - -. -. Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f l f /_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active S Passenger Generator Outdoor <br /> Latitude i ; Q Closed Q Altered <br /> GPS , 1 1 •; r ± '-� Hauler Q Indoor <br /> r--7_.�, Q Inactive S Truck <br /> Longitude - ! lD Planned Q OTR End-Use Container <br /> Business Type.(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 0-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 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer, Generator;.Hauler and End-Use Facility. ENFORCEMENT STrATiUS <br /> V A HAUI I IN_GMAN-51 MW N I EE RN REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC.§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 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 forNOV or FXTJ <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 t GIWMB Enforcement <br /> Q Q -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 Q In Compliance No Violations,per <br /> Q Q Other: §. - <br /> Comments <br /> See.Co__ <br /> Inspection Form Included: 0 S ,��.�_��•_�_� f�,,��.// 0 Q <br /> Comments Included:41Busin s RSignature. �InVpW �s Sign-a`tur�e(pVta17 d ll1)Pho�nDe <br /> Phone Number Number .• <br /> INSTRUCTIONS ON BACK Co,'r�c In pct, E�X A(M P L E - 2 2 3 62081 <br /> White Cop CIW Yellow Copy.Operator Pink Copy.LEA . ®. <br />