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07312040408 <br /> «;it. Waste:Tire Survey & Inspection Report. Inspection Report.Number � <br /> W sfateafca"r°m'' Survey Form - Page 1 1 3 - 10 7 3 3 2 8 <br /> r CIWYIB 181(New 01/0y <br /> Callfomla Indgnted Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O 1 �,1 / O ' Inspection Type (Fill one) <br /> Site Suffix: I �) <br /> ®Routine Q Reinspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB .Q Complaint Q.Educational Visit Q Other <br /> Business or-Facility Name -- <br /> Inspected By Inspector <br /> ca 'S � Ca • 3 R - l TfJ�� �� <br /> Physical <br /> Address <br /> Street <br /> LL (` / �� OI�_^_ J Inspection Data <br /> t� /`''fF— State /p Code Time In Time Out <br /> Business Rep i Title m'm 00 AM 0 AM <br /> PM m'm M <br /> 1-- —_J <br /> Operational-Status Tire'Type Business Role Storage Type <br /> t(V1lholelRTE): I I �] (Fill one only) (Fill all that apply)"(Fill all that apply) (Fill all that apply) <br /> Tire Co <br /> r f i r ! IDI I0 ®Active g Passenger ®Generator Q Outdoor <br /> Latitude Wto Q Closed Q Altered <br /> •1 GPS Q Hauler. Q Indoor <br /> I O Q Inactive Q Truck <br /> Longitude — I•�IJIJ Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) 111 <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government- Q Relreader Q Dismantler Q Tire Derived Fuel <br /> (9 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q.Hauler Q Agriculture Q Shredder Q Other t I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> MM��Ar4iDim milLsjTRrmoutiREMEMID _ Notice Of Violation Q Extension <br /> Q Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 11:1 <br /> / m <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 NO'or EX7) <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 eferred CIWMB Enforce ent <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 W n Compliance - No Violations <br /> Q Q Other: §, <br /> Comments i►i�DQG1Lt _&Z- ° Ii4Zs )LZ(riC-l.f S f QIfibro <br /> y W. 40-n o4 Dr a#A new -TP w4go- f1rYer�� <br /> Or, ih0gin nLI, ��IdX y . GAlin Ti c EDT"timif6�/r��ycs <br /> A4- <br /> inspection Form Included:Q —1 <br /> Comments Included:Q ti `7 Op)i o <br /> Bu ss Rep's Signature Phone Number . I c rs S n tura Phone Number <br /> INSTRUCTIONS ON BACK jEjkAjMjPj_CjEj 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> i <br />