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Waste Tire SAW/ey & Inspection <br /> ReportInspection Report Number <br /> State of California ■ <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1088239 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- r_ye S _T \ BLUE OR BLACK INK PEN <br /> _ y <br /> Business Profile Inspection details <br /> TPID- ` r Inspection Type (Fill one) <br /> Site Suffix: _I.-d �� _ JG <br /> - �� . 0 Routine Q Re-inspection Q Referral Q Observation <br /> �._f. <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCtn Toa 9 -k\n C0unt <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S <br /> Physical ddre _rn F Gr rr1 <br /> A L_I <br /> 5 ------ <br /> 3-72-5 Arra__ <br /> Street <br /> l _— � -__ <br /> . <br /> Inspection Date p [��L- <br /> Lod, - CA 95 2_qy 0 _ I <br /> City �` -- Mate Z(p Code Time In Time Out <br /> Business Rep Title O AM F_ O AM <br /> L-1_1 : [. . 'm F_ _] j 0 PM <br /> its` tMl 0fLQY <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude E—E] ; L <br /> ^ Q Hauler Q Indoor <br /> 7 � <br /> F --.�-- <br /> _�.._ 0 Q Inactive Q 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 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 ® Agriculture Q Shredder Q Other <br /> _J <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> - ' Q PRC§42951 -Waste Tire Hauler Registration and Transport <br /> ort of Tires Q Notice Of Violation Q Extension <br /> Q <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 / m / 7 <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB I <br /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Fogfor 3 years - -- (Required for NOV or EXT) ' <br /> 14 CCR 18459.2.1 -Submittal of Comprehensive Tri Los s within 90 days <br /> Q O <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers L Q Referred/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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> -_ �aufi1'�� no�'ec1 <br /> O��StGc,►�t},, dae nab �,cnera}� v3�`�.e ��res a1� -��reS on ro > (ter <br /> 1 ()C%1 td(,tmP-q.d . Ovanzc (e� _F_rrGnnon TIYe tc, aQ�`�drenllu Yernove �ICes . <br /> lUo v ,QAW�\ r,S r)Y' Ot`feCIS of colicernO <br /> . <br /> 10, <br /> w <br /> rrirt <br /> Inspection Form Included Q <br /> -Comments Included Q' <br /> Business Rep's Signature Phone Number I actor's Signaturef Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � _ 62081 <br /> • . •� � ,!Pj �jE; 9 21 1 <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />