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09049040345 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CatHom0la . <br /> CIWMB 161(Wew 04!041Survey Form - Page 1 - <br /> I1 1088361 <br /> CalMomla Integrated Waste Managemanl Beard � <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I I I I 0 Inspection Type (Fill one) <br /> Site Suffix: I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local (r,_, If Referral,choose referral type(Fill one) <br /> Identifier: I Son�0�'1,�\(� W1Q CHQ Complaint Q Educational Visit <br /> P Q CIWMB Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �cn5ouan Cbw��b_y R (�t;n��.nunce 3 9 - ) o I , n <br /> Physical Addr ss Escoio <br /> �Ib11 D <br /> Street E_.�i.u,�elkon_Ave. I <br /> r^ 1 <br /> Inspection Date <br /> o(N-56(NC� �t5ao51 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q O AM �� Q AM <br /> 1 A -�4j,� 0 PM 3 i.I J CJI 4)PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) W ( (Fill one only) - (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Ur ` Is Active ®Passenger ®Generator 0 Outdoor <br /> ,O Q Closed ®Altered <br /> GPS Latitude .O ®Hauler Q Indoor <br /> - Q Inactive ®Truck <br /> Longitude - Q Planned ®OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 e Hauler Q Agriculture Q Shredder Q.Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A MAULING AND MANIFEST RE0011REMENTrS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 <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 C-IWM 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 Ylolations <br /> Q Q Other: §• 1 1_ <br /> Comments QO—��nS-pC(,-1-1-6�1 d��U1��j1-�,r�-G�[1�►K��-O-I,b1,�1-1_f1��..U�l.s <br /> o +el Lo-ve�tu>z— <br /> Gn of Yt �artr Gtis.posal_. <br /> Inspection Form Included:Q 1 ^ 10� <br /> Comments Included:Q-\'d✓ J—- - JIJ{'`-S <br /> Business Reps Signa ure P 4 Number Inspector sSignature Phone Number <br /> INSTRUCTIONS ON BACK C►orrect: Ineorrect�, 1 E jXI A jMj P[L I E! 1112131 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LFA ■ <br />