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07312040433 <br /> j� Waste Tire Survey & Inspection Report - inspection Report Number <br /> State CIWIVIl81iNmla Survey Form - Page 1 1 2 - 10 7 3 5 2 5 <br /> CNYM8.191(New 04/04) <br /> califomla Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z y - O / Inspection Type (Fill one) <br /> Site Suffix: I ' T Routine Q Re-inspection Q Referral Q.Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: "`p�e � ( �,;E,.Y Q CHP Q CIWMB Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name. Inspected By Inspector <br /> Physical Address~ s(flC.1L1 I KE _ (j7/ <br /> 7 � L 11/�►t^Gt <br /> 22-22- £. <br /> Street <br /> Inspection Date O •� � � � / O <br /> CA ` zlo <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title QAM Q AM <br /> —� m m 0 PM m' 0 PM <br /> - — / <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 I r *Active Passenger 40 Generator ®.Outdoor <br /> p$ Latitude - _ O Q Closed Q Altered <br /> Q Hauler Q indoorGH .LJI�J �mQInactive Q Truck End-Use Q ContainerLongitude - �] _ I Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment. Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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- E. ---EMENT STA_T_US <br /> V A ,H ULING 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q <br /> 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 7 <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days. (Required for NOV or EXE <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 I CIWMB Enforcemen <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 /> k[S7' -Ys•'L—• l/'LSt�l�f'UM.=Ohr3_pC,l.�i+—/!L9'_SifC+,c� -(.S}4— --- <br /> l✓er-t S•t..c�1�2-�—bz 9_8 rJ�L,�,:�s�rc.�s—u��d��/Vv <br /> Via(r+fii_uv�s_ <br /> — = <br /> Inspection Form Included:Q <br /> Comments Included:Q— - - - Zf`f yb$^b�z3 <br /> Business ep' Signature, Phone Number nspector's Signature 7 Phone Number <br /> INSTRUCTIONS ON BACK •rre Incorrect: 62081 EXAMPLE' ] 23 <br /> ■ While Co .CIW Yellow Copy Operator Pink Copy.LEA ® ■ <br />