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08123050064 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> 't1a_ state of California ■ <br /> Survey Form - Page1 11 - 1073433 <br /> CIWMB 181.(New 04104) Y <br /> Callfomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f I�� y Inspection Type (Fill one) <br /> Site Suffix: I ^otan 1 l 0 Routine Q Re-inspection Q Referral -Q Observation- <br /> Local Qh SIf Referral,choose referral type(Fill one) <br /> Identifier: OQlQU�(� CQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> LT_r 7,mc_yy L o-5-L-A <br /> Physical Address,) ' U ` Lll'.r E;, -ian_{_t,.rn a's <br /> I <br /> Street Inspection Date <br /> II sto c._•-V0nv CA g�S�_z�o�6_�, <br /> City State Z/P o a Time In Time Out <br /> Business Rep Title 0AM O AM <br /> :M 0 PM E] O PM <br /> Man — <br /> Operational Status Tire Type Business Role Storage Type <br /> j l jo (Fill one only) (Fill all that appy) (Fill all that apply) (FIIl.all that apply) <br /> Tire Count(Whole/PTE)'. '' r 15 <br /> l.. 0 Active Q Passenger 0 Generator 0 Outdoor <br /> `O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> L <br /> . - O Q Inactive Q Truck <br /> LongitudeL. <br /> , Q Planned 0 OTR Q End-Use Q Container <br /> Al <br /> Business Type (Fill all that apply) <br /> 1111 Txofkr <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 1 1 <br /> Q Service Station Q Hauler Q Agriculture, Q Shredder 0 Other L�IStr!bit-1_IOC\G�tef.J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEM NT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Z -7 O & <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 or 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 Q3 Referred FMGIWMB Enforcement <br /> Q tQ 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 Q In Compliance - No Violations <br /> Q 1 Q 1 Other. § <br /> Comments R0._l�-►f1Q. �Y1�'�.2. w�Q[� -+'1'tIS—t��u\2 � -k�+c__ �lO�l Q�A1_gS "o <br /> �G�lt a ca�e.S�Q( (� es Qli.a ill 6tb Ar,cordaki <br /> z r�ortne l� �La.Si� oY �L7�1xe.S—are—s _�e t��fl �c�u�`y -CY�nSDor�a{r�n <br /> Inspection FormIncluded:Q <br /> Comments Included:O) f <br /> SIneSS S Si ure Phone Number I ors Signatu a Phone Number <br /> INSTRUCTIONS ON BACK Correct: tnsorrect: E X a M P L Z 2 3 62081 <br /> ■ - White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />