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09255040658 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB 1B1(New oa04)of California <br /> Sur <br /> vey Form - Page 1 Il <br /> - 108696 0 <br /> Crvv <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j G �<j <br /> Inspection Type (Fill one) <br /> Site Suffix: L I 6 15 <br /> 66 ® Routine ORe-inspection OReferral <br /> Q Observation <br /> Local � �1 r l If Referral,choose referral type(Fill one) <br /> Identifier: `��� )cck. V '" l ���"'� J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phjrsical Address r I Ltici) d t,H1-6_y Amby <br /> Street <br /> (`� Inspection Date <br /> Cry CI <br /> ca State Zlc Time In Time Out <br /> Business Rep Titler� 10 AM f—� � Q AM <br /> I- --I V�� ® PM �- `� `� v I QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) v <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> . ..._� <br /> r f 0 Active ® Passenger • Generator ®Outdoor <br /> O Q Closed •Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <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 <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 Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EX7) <br /> Q Q 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 /> 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 P f� e <br /> �� — -[_ _ <br /> �) l o-ei-i k m_�rq <br /> Inspection Forth Included: Q <br /> Comments Included: Q — -`16P?6 7 <br /> Business Rep' Signature Phone Number, Insp cto s Sig toe Phone Number.. <br /> 62081 <br /> INSTRUCTIONS ON BACK C rr ct: Incorrect: X A P 100" 11121:3 <br /> White Cop CIWM Yellow Copy:Operator Pink Copy.LEA <br /> I <br />