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08206040087 <br /> Waste Tire Survey& Inspection Report. inspection Report Number <br /> rs State of Calllornla <br /> cIW**181 c""'_ gaw, Survey Form -- Page 1 I'� 7 - _1 0 7 9 2 9 5 <br /> cell/omla Integrated Waste Management eoard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 3 2 Inspection Type(Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 70^ � (py.� "-Y� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� Inspected By Inspector <br /> Physical Address J <br /> 1 4040 0 - Aksr I <br /> Street /� Q <br /> I z_1 <br /> l _ ���� I Inspection Date <br /> City S State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> __Q f`i- 1,060tL—,LAtd _ m m 0 PM m m 0 PM <br /> ----J Operational Status Tire Type- Business Role Storage Type <br /> Tire Count(Whole/PTE) ( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ! ' 4111 Active - 0 Passenger 0 Generator Q Outdoor <br /> Latitude I �O O Closed Q Altered <br /> Caps •�I ��I� O Hauler O Indoor <br /> T 0 � O Inactive I*Truck <br /> Longitude _ — I_ I I O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) ttt ���JJI <br /> TQ Dismantler New Tire Dealer Q Auto Repair O 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 —O Agriculture Q Shredder 0 Other 6t''R•(A�yy <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STgTUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice of Violatio Q Extension <br /> O O <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / [11 / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> ��) _./e _�(� �,�,..�•��,,,,c..�: _ _.—C.,�-amu...... c���.',6�.1�.� <br /> _J ✓0"r'r1id . 1 {I <br /> p Id�a� _Y�SQ,��_U•�/lS Ne7LJO. <br /> Inspection Form Included:0 .. 10 <br /> Comments Included:Q — �pCf, ��—� �$ ��'}� <br /> Busine s Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK 711 'o �. jEjXjAjMjP[L E 1 :2 3■ White Operator <br /> Pink Copy:LEA <br />