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07MO30425 <br /> Waste Tire Survey & Inspection Report . Inspection ReportNumber <br /> rr sor c rmia <br /> sr CIwMBlam181tNowto04/04) Survey Form Page 1 1. 4 1 .01 3 2 9 2 <br /> Calltomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN, <br /> Business Profile Inspection Details <br /> TPID- ` O /, Q / Inspection Type(Fill one) <br /> Site Suffix: ` 7 / _$Routine Q Re-inspection Q Referral Q Observation <br /> Local 6 �^ If Referral,choose referral type(Fill one) <br /> Identifier: + �Lwh Q CHP Q CIWMB Q Complaint Q Educational Visit.Q Other. <br /> Business or Facility Name <br /> L_,Ad� ,^�;n^� Inspected By Inspector <br /> ko l l-C-l� <br /> Physical Address <br /> 02� <br /> 01 <br /> Street <br /> L 5*CkITY-7 0_4 ���� I Inspection Date / <br /> City State ZIP Code Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep /� Title m'm O PM EEI'm O PM <br /> Operational Status Tire Type -Business Role Storage Type <br /> Tire Count(Whole/PTE),�t ff <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J __L ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude �. Q Hauler 01 ndoor <br /> o QInactive ®Truck <br /> Longitude _ Q Planned ®OTR Q End-Use IS 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 lm�lll�r„ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder IS Other L`S yQ d— Y-epaAr <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT <br /> V A ;HAULING AND MANIFEST REQUIREMENTS Q 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 0. PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements IT] <br /> / m <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 EXTj <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0.- 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 fzxL I K.S— `" 7 V4 t.J d-cite a 'LtA H cogs xt, ` fJtJc &ailk <br /> �scs vine, fruck,_veatsi-¢-ed—der Reef-rim 67PO1001 94 rwas /used fir' <br /> D � o r 4ria r r ail+: 5tv e- yurd �tYta.�l_evs ciem inspeckd. <br /> elL ts rimer ,a Few o� wcv(:fu Fir - <br /> Inspection Form Included:Q IV <br /> Comments Included.® Y& 7 l rPYr <br /> B 1ness Rep's Signature Phone Number I pec g lure Phone Number <br /> 62081 <br /> INSTRUCTIONS.ON BACK Correct: Incorrect: X A P ;Lj#[ 111213 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />