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07312040421 <br /> ery <br /> Waste Tire Survey & Inspection Report- Inspection Report Number <br /> State of California' <br /> CIWMB 181(No.04104) Survey Form.- Page 1 I.- 5 - 10 7 3 5 6 9 <br /> califomia Integrated Waste Management Board <br /> PartA-Survey. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J7 3 6 ®Routine Q Re-inspection . .Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . . <br /> Identifier: : � _ 1"b G.06t.4,� �yfuMl v� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business'or Facility Name Inspected By Inspector <br /> I f�f u.QaA �zsoul.s—L.l�c <br /> Physical Address .. <br /> 1 6o W- S+v, <br /> Street <br /> Inspection Date �- <br /> tsr <br /> city State ZIP Cade <br /> Time In Time Out <br /> Business Rep AA. TitheO AM O AM <br /> M I"{rk�oI--vu PIuMJ m FUGPM <br /> m m ®PM <br /> � � � Operational Status, Tire Type- Business Role Storage Type r. <br /> Tire Count(Whole/PTE) I I I( <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill.all that apply) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> r rFTI <br /> GW <br /> Q Hauler Q indoor <br /> PS Latitude 0nactve Truck <br /> Longitude Q <br /> Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) <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 ®Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST KEE—OTWU IREM ENR51111 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 /> 00 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 D(T) <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 /> 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 /> t d$. 2a—�t�-'4.�5 L• f�rZar t+tcrrr�/_r 1lIG��r <br /> Inspection Form Included: Q <br /> Comments Included:Q <br /> $ --D 6 Z-9 <br /> Business Rep's g urs Phone Number spector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect•0 n¢orrect: E X A M4 P I: E 11-1213 <br /> ■ White C py:CI Yellow Copy Operator Pink Copy LEA ® ■ <br />