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973i �u4G4ti6 <br /> ne- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 181(N..04104)o4l Survey <br /> crvvme tef Form Page 1 I fi - 1 0 7 3 3 2 2 <br /> California Integrated Waste Management Boats - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> Site Su <br /> rfix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L__TcLc .6 d Pa <br /> ca _ <br /> Physil Addros 3 q EGE] <br /> L._v" 'r vim-'! ► tit�� <br /> I )3'75 "Tracor Blvd <br /> � <br /> Street O / / <br /> � ���A, (0I Inspection Date <br /> City State ZIPCode Time In Time Out <br /> Business Rep Title - <br /> �,j, [ Q AM Q AM <br /> t Ll K, I It l /Lf� - -' -- - �-J Q PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)! i 12 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r ,3 ®Active (4 Passenger ®Generator le Outdoor <br /> 0 0 Closed 0 Altered <br /> GpS Latitude — _ O Hauler Q Indoor <br /> • r O 0 Inactive Q Truck <br /> Longitude - �J� FTI <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> to Service Station Q Hauler O Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING A N DI M V'N I I.E SjTd REQUIREMENTS <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> 0 O .PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate m / ID <br /> / m <br /> 0 Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> ui <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Reqred(or NOV or EXT) <br /> O 0 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 Referred!CIWMB Enforcement <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 1010 1Other: § <br /> Comments ;..n w —��We� `Mt-� <br /> CJ(rl.r u" r vC����e7-(JtWf •�n <br /> hGu.�2S—IOW�Va� �o� Wa�l�illeS7}ae - <br /> cAJO <br /> Q o(tS- <br /> Prcbf CF Alli u_anii >vIa__inadivii <br /> Inspection Form Included:Q ,q c� �T 01� ��a,�p <br /> Comments Included:Q ao9)_8�5�77?� �]�� Otp-� � <br /> BusinessVs Signature Phone Number 1 ector ignature phone Number <br /> INSTRUCTIONS ON B K Corrre¢t:�_ Incorre-ct: <br /> 3rEjXj AIMAIMI P I L FEFJ I ji I il 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> FILE C <br />