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08206040145 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> ;r C1WM 181(Califomia Survey Form - Page 1 1 4 - 1 0 7 9 2 6 8 <br /> C NMB 161(Naw oaoa) <br /> Callfomia Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:. ! 3 $ G 3 / V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _r If Referral,choose referral type(Fill one) <br /> Identifier: ��p [aN Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L � T_�t-s 4_w.Gl�cj_s- , <br /> Ph sical Address I?RK <br /> I 2252 VJ!�T /a(,00 f LA <br /> Street <br /> Inspection Date <br /> City State ZIP Cade Time In Time Out <br /> Business Rep Title OAM Q AM <br /> Zeo c m'170 PM O PM <br /> —- -� Operational Status Tire Type .Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 <br /> 1 ®Active *Passenger 0 Generator •Outdoor <br /> I 1 <br /> LatitudeO O Closed Q Altered <br /> GPS <br /> QHauler Q <br /> Indoor <br /> Q Inactive Q Truck <br /> Longitude —1 _11 <br /> _1-1TI1o Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORC-_EM_EN1T STATUS <br /> ----—. <br /> V A HAULING 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 Date m / m / [I] <br /> O 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 (Requi ed for NOV or FX7) <br /> O O - ----- - --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/GIWMB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> IV <br /> Inspection Forth Included:QI �" p <br /> Comments Included:Q <br /> BusinessRep's_Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C► rrect• Incorrect: E XA Ml PL E123 62081 <br /> ■ White Co .CW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />