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08262090546 <br /> Waste Tire Survey & Inspection Report .Inspection Report Number <br /> Bfateof Oat(N- Survey Form - Page 1 - I1 - 1088256 <br /> rr'y CIWNB 181(Naw 00!06) <br /> c-lifomla Integrated Waste Management Board Y 9 <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- ' I I O ' Inspection Type (Fill one) <br /> Site Suffix: 1 y I*Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JQ�J 3w Iv C ��y Q CHP Q CIWMB Q Complaint Q Educational.Visit Q Other <br /> Business or Facility Name uu (� Inspected By Inspector <br /> L_i aFems rs 13 4 - Ff o , NAznr=� I <br /> Physical Address <br /> L_2_ZD F o5�i rf— AV¢ . I - <br /> Street <br /> Inspection Date <br /> LN�� C.4 9 533E , <br /> Crty State Z1P Ccde Time In Time Out <br /> Business Rep Title I 0 AM F 0 AM <br /> 0P �' 0P <br /> j —Jet_41.�_MA 2ie, ow.je.a ---- <br /> Operational Statue I Tire Type Business Role Storage Type <br /> my (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude j i D Q Closed Q Altered <br /> -- -- '- -`--1-- — Q Hauler Q Indoor <br /> Inactive Q Truck <br /> Longitude Q Planned 10 OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <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 i Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> P r Y --- --------- <br /> V A HAULING AND MANI EST R Q REME T <br /> Notice <br /> Q Q 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 !Not ne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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 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 Com Ilance - No Viola to s <br /> Q Q 1 Other: § <br /> Comments �7 f <br /> )— 41 eh <br /> f�J�V_;a_(hr►.Ns oz Coy, CerK.s h?c')rzef. 'zgx <br /> InspectionForm Included: <br /> Com <br /> Comments Included:Q <br /> sine p -.,Signature hone Number Inspectors Signature• Phone Number <br /> 62081 ,_ <br /> INSTRUCTIONS_CIWBAC .05 Exec : Incorrect: E X A M P L E; 1 2 3 <br /> ■ Whit Copy CIW Yellow Copy.Operator Pink Copy LEA ® ■ <br />