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L Waste Tire .Survey & Inspection Report Inspection Pott umber <br /> - Stale of ( <br /> t181No.04104) <br /> lfomia In egmed WasteMa amnt Bad Survey Form Page 1. I 0 7 ^ U <br /> 'art ACafSurvev <br /> BLUE OR BLACK INK.PEN <br /> Business Profile Inspection Details <br /> ( TPID- - Inspection Type (Fill one) <br /> Site Sum.: 3. C_ p -h 2 O 0 Routine Q Re-inspection Q Referral Q Observation <br /> LoralIf Referral,choose referral type(Fill one) <br /> Identifier: SQn V T O CLgtAt11 GOLL()+l Q CHP Q CIWMB Q Complaint Q Educational Visit.Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Lx I <br /> Physical Address ?j Q <br /> 11 <br /> LK_f►S�'lan Luras I <br /> 1O'Z l unser. flc. <br /> Street <br /> 1 Inspection Date <br /> qt Time In Time Out <br /> Cify t CA State 5 P C-oode <br /> Business Rep Title O AM O AM <br /> WOPM �' OPM <br /> R�cha�d_ _8e�tStQClds_ILsho. M_r_., <br /> J P—'-_9 Operational Status Tire.Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ I t I .� 0 Active Passenger 0.Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude W. I � Q Hauler Q Indoor <br /> 1 O Q Inactive Q Truck <br /> Longitude _ 11 _1_ 1 <br /> III I. 17 I1 Q Planned Q OTR Q 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 0 Auto Body Q Car Dealer Q Collection Q Crumb,Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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-RegistrationfDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EXT) <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 Enforcement <br /> Q Q 14 CCR§1B461-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 0 In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> �O_Ujl17Q—Lt15.��GtIOQ—R2S_UCMQC'�1\S�GCf2 �t0(tQtaJ,� _w45 rLo-t-e.d.a <br /> ►=as i1\� t lot uolu g e1 cw�lca�_r ��ash + S_.—Q_nly—ma.D►�eS-�v i�t,��cLt.xs <br /> �c� 03�('��2`{ �nlnn Jo c s4ra�efJ�'�C�'_—�'L2�f�l►� nrs�- InA�_c,�,tnr4o -F-�rp 1-uo,U�4,k— <br /> )2�Ck_1p kit_ 4­94 �_ �rS- 715r $ an eSdtCL9 fQNi( fKltfTEs . iJo V IQ`a�irtcis or ACS_nd� . <br /> Inspection Form Included:Q (zk) <br /> Comments Included: =o5—b� -- 44�01q6�7�(t <br /> Bu ine Rep's nature Phone Number I ctof's Signal Phone Number <br /> INSTRUCTIONS ON BACK orre Incorrect: 'E 62081 <br /> � ��, �� �' I Gxlann�lPl�l�� I��2131 <br /> ■ - White y:CIW B Yellow Copy.Operator Pink Copy.LFA ■ <br />