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081S7040074 <br /> Waste Tire Survey.& Inspection Report Inspection Report Number ■ <br /> �r State of California <br /> CIWMB 181(No.04104) Survey Form - Page 1 1 5 - 10 7 9 2 2 8) <br /> califomla Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r� '/� ��� Inspe tn Type (Fill one) <br /> Site Suffix: LIIf I N/ IL (JAI a{JI Q Routine Q Re-inspection Q Referral 40 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L6Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L-0, --- <br /> --k- 7%tee <br /> Physical Address <br /> I 2 4 5D (ALA <br /> Street O / / <br /> 15�3 �� 5 I Inspection Date U CI�Jj <br /> tC y Stafe ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type. r <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) i f. i <br /> 215 •Active Passenger Generator 19 Outdoor <br /> i-- ,— - O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -�— --`-- - Q Inactive Q Truck <br /> Longitude - I �L1 L I L I I Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) l 111 <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <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 /m <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 DC7) <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 1 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 Q1 Other: § <br /> Comments gt. 7t/ dale 7;w— A.M6-wi^l.IW AjOLS-- <br /> _ y'(r�d:—ifs •fuLi__vs�s INt�tt/ Aa.jr_/_!_ 3er'� <br /> ��� G��.ti• sT�,_; _Ma",i�c�ST r��y_oH �rr►es drstycss� <br /> I <br /> —IJe_✓-%a/_�-vMS o2_C_srlGc,r_t f�o�. <br /> Inspection Form Included:Q zoct <br /> Comments Included:Q - � v S <br /> Business Rep's Signature Phone Number Inspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr Incorrect: 10XIA11M P L E 1 2 3 62081 <br /> ■ White Cop.CN Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I � <br />