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t., <br /> 0',8227040058 <br /> Waste Tire Survey & Inspection ReportInspection Report Number <br /> ss Sbta OT California <br /> CrWMe 1:11(New104W) Survey Form - Page 1 1 6 1. 0 7 3 4 5 4 <br /> califomia Integrated Waste Managamant board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / D S / / (1 / Inspection Type (Fill one) - { <br /> Site Suffix: *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� �a�p Qie,�i^/ .Cpo�.J'7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d) Inspected By Inspector <br /> T Allo ra2sPo,� 1 <br /> Physical Addres <br /> lStreet <br /> 3255 Au--r_2, J-L-f21 <br /> Inspection Date <br /> 9s3��� <br /> i City Stafe Z/�Gode Time In Time OuY <br /> Business Rep Title O AM Q AM <br /> �ba m'E70PM T1 QPM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE I� 1 <br /> ` , 11 I 1 - i i 0Active Q Passenger 0 Generator Q Outdoor <br /> FL]. IT�O Q Closed. O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Ir O Q Inactive Q Truck . . <br /> Longitude - I Q Planned Q 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 0 Other l/1d7AQtt�/G�OFF�i{s� ctet I <br /> Part B-Inspection of Waste Tire Dealer,Generator,.Hauler and End-Use Facility: ENFORCEMENT STATUS <br /> V A ,H ULING A D MANIFEST REQ E ENTS <br /> Notice Of Violation <br /> Q Q PRC 42951-Waste Tire Hauler Registration and Transport of Tires Q <br /> § 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 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 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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q 1Q Other: §, <br /> Comments � /l <br /> /�-�rr l� /r��'P�►'ts3 ly�±•+ �fiN�.o—n,� C./2p_.�—�npTiA' <br /> � <br /> 0#15 0"4 OlG (I� -� /,�LS T CaJw/ '7�ifft_ <br /> •-�9.—I�0__1/�1.4, <br /> Inspection Fomt Included:Q. _ Q�p� Q� <br /> Comments Included:00. <br /> — Mune Number <br /> Busin s ep's g ure Phone Number Inspector's Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKC rrect: I correct: E X A M P Nr EI 111213 <br /> ■ White PY CIWM - Yellow Copy Operator Pink Copy LEA ® . <br />