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09 ,8,0,040913 <br /> L Waste Tire Survey & Inspection Report jnspection Report Number <br /> State of California <br /> CIWMB a5teManag) Survey Form, - Page 1Ltl�::-: 11_41181 <br /> California Integrated Waste Management Board _ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - 5 I1(_9 <br /> � � Inspection Type (Elle one) <br /> Site Suffix: I L Q Routine ® Re-inspection Q.Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: Ls vv J b �1' 1 C�,,,�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> by 1Q <br /> Physical Address 13 ) LV <br /> I 1 --a <br /> < ( J <br /> Str.LG�_A�_ <br /> et —� 1 <br /> GAInspection Date H Time In (I—_— Time Out _ <br /> City State ZIP RIO <br /> Business Rep Title I AM I �� Q AM <br /> 1: I o 1 . 1 l• �-�i�QPM Ll� � I • IV � �1 QPM <br /> Operational Status -Tire Type Business Role Storage Type,- <br /> Tire Count(Whole/PTE) � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' Active ® Passenger QGenerator <br /> Q Outdoor <br /> Latitude -` - j —.I- _i-. -- _IO 0 Closed 0 Altered <br /> GP$ I • I_� L_I •Hauler 0 IndoorN/A <br /> T 10 0 Inactive 0 Truck <br /> Longitude - I I I 11 1 i f 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler. 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer .0 Collection 0 Crumb Rubber <br /> 0 Service Station Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS, <br /> r 3 <br /> 10 t0EST_REQUIREMENTS1 4 <br /> QX <br /> V,, 'A AAU,LING�AND' Notice QE Violation, +t�,Exteio <br /> nsn >; <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �$ � �' ; �-� <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. >°C mpli ce Deatll(ne�?, , <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ` <br /> . t +x <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 00 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 014 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days <br /> a� (Requcecl=for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years , ,•„ ;;k .. , <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CiwmB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities r; <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> Other. <br /> , <br /> 0 0 (� Q .� x �'•� 4'~<� �:�.� ��- <br /> ijComments �� �_�-1 Q I• Q. <br /> 0(� ��nn15 <br /> ADNATIMh-wv- <br /> Inspection Form Included: I• �`� <br /> Comments Included: Q v - l &Ms� A <br /> -\JO� ( — <br /> Business Re 's i natur Inture `p g Number Phone Number . <br /> a i � s 8 62081 <br /> INSTRUCTIONS.ON BACK Corre t: Incorrr ect: �J X R h7 P L 112131 <br /> White Copy:Cl Yellow Copy:Operator Pink Copy.LEA <br />