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09182.04.0398 <br /> =i Waste Tire Su&y & Inspection Repor ., Inspection Report Number <br /> 'EES. <br /> EeE1 State of California <br /> CWVMB 1st(Now Manage) Survey Form - Page 1 1 7 - 1 0 7 9 3 2 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i ( I O-r6 I Q a F l O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local —7— If Referral,choose referral type(Fill one) <br /> Identifier: ISW l I — � _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. �/ ,,I Inspected By Inspector <br /> L—A C� Tr(�L�-F�t I <br /> Physical Address aEJ,- <br /> vvv �.7 <br /> I q 05 S. V a <br /> Street <br /> n G Inspection Date O`J <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM C 0 AM <br /> A�, B_rj a(�Q,J'/ /, �'_, 0 PM U -.J ® PM <br /> -- Operational Status Tire Type Business Role ' Storage Type <br /> Tire Count(Whole/PTE) 1 ' i / (Fill_one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� ® Active Q Passenger ® Generator ® Outdoor <br /> j l l IO Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> - -�--J - !--I-- _ <br /> Q Inactive ®Truck <br /> Longitude — C. I ^I , I I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 <br /> Q New Tire Dealer Q Auto Repair ® 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 /> V AHAULING 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 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 EXT) <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/C-IWMB 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 C-ompliance - No Violations <br /> Q Q1 Other: § <br /> Comments K0V47�hR_ M-7 Q� l. <br /> �f o� r Y►�I S n 0 `l �) • <br /> BrolLrM on 7-ire- 0 Ac_ Co T''� <br /> lee--f- `-1-i vice c� 's osa,�)s, 7' 0- M Aest- <br /> �r m S V i elk/-P1-' Mo ✓I(,f 1 . <br /> Inspection Form Included: Q <br /> Comments Included: Q �dtt�L <br /> Business Rep's ignature Phone Number Inspector's S nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C. re�c Incorrect: E IXIAIMIOf L I E : I 12 3 <br /> White Cop CIW Yellow Copy.Operator Pink Copy.LEA <br />