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rInspection Report Number <br /> „i Waste Tire Survey & Inspection Report ■ <br /> u State o/Calif <br /> (Now SurveyForm - Pae 1 f 1 - 1 01 3 0 59 <br /> C g.l 181(New Mlg. <br /> Celaomia Inlegrotetl Waste Management Board <br /> Part A-Survey BLUE Q$,B�CK INK PEN <br /> [Business Profile Inspection Details I} <br /> Site - �1_ <br /> inspection Type (Fill one)Site Suffix: iI0 J_ ! 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local IIf Referral,choose referral type(Fill one) <br /> Identifier: I J O 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> SQ}'t Physicall Addr� JA L+�I C tl��"LN�fLr C�tLcbt�I <br /> / ^I_.h Ave <br /> Street D O <br /> Inspection Date ! ? I <br /> I S V1C' g5a05 <br /> City - State Z Time In Time Out <br /> Business Rep Title O AM l O AM <br /> m'IT] M O PM <br /> ASO.- - = _ _ <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i t t 1 � <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Latitude 0 Closed ®Altered <br /> GPS L-_O 0 Inactive ®Truck Hauler 0 Indoor <br /> O <br /> Longitude - 0 Planned 4k>OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet I®Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V1 A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 1 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m <br /> 0 j 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required/or NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Farms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: §. �r,'" y./ <br /> Comments �D e //L�i�QrrC.Lun'( �S Me. !mak 611%4x meg'— �ppedf t_1 Triq ^y�,iNn� Ii{✓l �kl_ <br /> OLt— _Qasf Ael OF RrO( e`rr�S_bro_ kt f0 Tu Ki)AfX r��tt - <br /> /1wl�g �m12U417:4__�$j eut FDr <br /> LSA oCocuw�e ��F—' la_Se.Tire t� ( <br /> ah_0 . -`S ✓l _. ar ire <br /> Inspection Form Included:0; ure ,'�' <br /> (�Comments Included:®' - �O g (li) <br /> Business Rep's nature Phone NumberI actor's natPhone Number <br /> INSTRUCTIONS ON BACK ICorrect:O In rrect; )(� U II�IXIaIMIPILIEl 1112 13 <br /> 62081 <br /> ■ While Copy CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />