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08297040057 <br /> Waste Tire Survey& Inspection Report Inspection Report Number, <br /> ■ Yr State ofCalNornia . Surve Form - e.1. - I1 1088243 <br /> Or cNVMB 181(New 04)04( Pa Y g <br /> ca"fomla Integrated Waste Management Board �J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: { 5 2 7 3 2 Q O Routine Q Re-inspection Q Referral 0 Observation <br /> Local __ If Referral,choose referral type(Fill one) <br /> Identifier: .CC>qtl SO O qU%Y% C d UrA'%j Q CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Desigqn _ood-.�erk�h_ <br /> Physical Addreds 3 9 - 51 O M LK6sin Qn fL49as__J <br /> r 7-0 g N___S_acr-avn.P_Y to s+. I <br /> Street <br /> e� Inspection Date <br /> L—Lo.d1 C-AI cisz-�J Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title O PM F1 O PM <br /> - <br /> ----- Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i �/ (Fill one only) -(Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r r O Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 1 O Hauler Q Indoor <br /> I— — --I— <br /> _1 J1 <br /> Inactive Q Truck <br /> p � N/N/A End-UseerLon nude 1 Q PlannedQ OTR <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 Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- ROEM - -------- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 NOV or E C� <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 Referred/CIWMB Enforcement <br /> I <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 O (Other: § <br /> Comments <br /> _�a t'1-res_Sj'or_ecL—o�1-s �t._.�aGt1��-�+eoa�—o_�m� laer4" ecte.ra � Q <br /> ir_�s—fir�eQt[_.—Egc.ili y_cu�r�cen�ly e,ra e ---- <br /> -Ke-e.of~►_.L�en d�-o—ilnaci-i_v_Q�•¢.T P_1.D =�' �5�1-1_3 Z-01 . <br /> Inspection Form Included:Q <br /> Comments ncluded:Q Business Rep I natue I <br /> atre - PhonteZ�Number <br /> Phone NumberK_1-?rs <br /> - — � <br /> 62081 <br /> INSTRUCTIONS ON BACK C rest: ncorrect: X a M P L E 1 2 3 <br /> ■ White Co .CIWM Yellow Copy Operator Pink Copy.LEA ® ■ <br />