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08227040115 <br /> L= , Waste-.Tire Survey Unspection Report Inspection Report Number . <br /> �� $ B CalHornla Survey Form - Page 1 13 - 1 01 4 8 8 3 <br /> C'WM8" 1E1(New 04/04)Caleomla Integrated Waste 101 a9 ,Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- � f � - � � Inspection Type(Fill one) <br /> Site Suffix: L/ 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc�,, <br /> IfReferral,choose referral type(Fill one)Identifier. F<§. j �7o � Q CHP QCIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name W <br /> V Inspected By Inspector <br /> p£nI s1C.� C.L tom►S14 Coy L?, q <br /> Physical Address M01 .eL <br /> ��E QfS c4D� Ay&_ I — "`TTTfii��� ALN <br /> Street D [� I ©8 <br /> 95 O� InspeclionDate <br /> State code Time In Time Out <br /> Business Rep nom• Title O AM O AM <br /> � lei C-I�JLi �crc,�� ,`T^' T PO/fr WM► O PM 'm O PM <br /> f 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) <br /> r t 0 Active Q Passenger •Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 19 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 Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use.Facility ENFORCEMENT STATUS <br /> V A HAU IN D MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Oi Violation 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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - - -- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Refe11111 MBIJEnforcement <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 1n Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> /—g1�a�,�x._,—Tlt,�. owr%� w �.a <br /> a _ <br /> t <br /> l -a-t.o LI)J 10 ld 7- •t0 Ae... <br /> firm a.r.•�+-_ _a�t,f s—d' �Mr: v,—ts Ole <br /> Inspection Form Included:Q <br /> 41,E 4��3 <br /> Comments Included:Q - <br /> I ;in ss ows lure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr!I b Incorrect: EXAMPLE 1 '2 3 62061 <br /> ■ White Copy. I M Yellow Copy Operator Pink Copy LEA ® ■ <br />