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o9a84440892 <br /> ifiWaste-Tire Surve <br /> y & Inspection Report Inspection Report Number <br /> State of California . <br /> CIWMB181(Now 04/04). ' Survey Form- Page 1 I I1 - 1141211 <br /> California Integrated Waste Management Board <br /> part A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffi <br /> TPID- '--? I I - Fo 1 1 <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: L h - 0a - '� C87A J Q CHP .Q CIWMB Q Complaint -Q Educational Visit Q Other <br /> Business or Facility Name - B <br /> Inspected Ins <br /> ��� ` ) f n -•L��/,fc- I P Y Inspector <br /> Physical Address r-Y a <br /> 30 <br /> Straei' i `1 <br /> L4R*KO11 <br /> � q5 3 3 Inspection Date —Q�8 J / O I (7�_qj) <br /> City State ZIP Cods Time In Time Out <br /> Business Rep Title I--�--�®AM r—�- <br /> CAM <br /> �/�,, &_A_ 4q_ <br /> �' i t � 0PM I_� j— ' I -10 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger Q Generator Q Outdoor <br /> Latitude I I I i0 Q Closed Q Altered <br /> GPS I ( •L^I-I -_I_IQ Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - i ; I I Q Planned (DOTR 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber �_ ' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other I <br /> Part B'- Inspection of Waste Tire Dealer,.Generator, Hauler.and End-Use Facility. ENk -R MENT„STATUS" ° ., <br /> V A , <br /> AULANMANIFEST REQUIREMENTS QN "oftl �� <br /> ._ _ - . :. �. n ':.. ,ate _. . <br /> R otice R Viola on*4Q�E a sion - <br /> Q Q PRC§42951 -Waste.Tire Hauler Registration and Transport of Tires ,,: :' _ ?• <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. � Ate' k" <br /> Q Q § 9 Compliance. Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements p ;,Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB / m °x <br /> r _,fi <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Requrredaor NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 4 ; 4 _1 � ». a '-tea <br /> -. <br /> Q Q. 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q^„Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities �..� �4 <br /> Q Q 14 CCR§18462-Manifest System.Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - Noy Violations <br /> Q Q Other: r64 ” ' "" P <br /> Comments <br /> 1A Ao L <br /> _U�s s pc $, wta.21VAa,Qd �v rP.rn o vf_ JIPAJ?re S • <br /> - rvs sty-VI ud 6 FF "We' Cor"'? cid t 66 ,f r )- s's <br /> q1� f-en -'res rtmo✓ed alt- i 16 t/►'o <br /> Inspection Form Included: Q <br /> Comments Included: Q Ati- <br /> p's Signature Phone Number Inspector's S' ature Phone Number <br /> INSTRUCTIONS ON BACK Corr ct:' f correct: ( 1(EbXj AjjMj P 1 L I EI 111213 62081 <br /> White Copy: IW Yellow Copy.Operator Pink Copy:LEA ■ <br />