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.. 091820402 ,18 <br /> eee_ <br /> Waste Tire Su&y & Inspection Repor Inspection Report Number <br /> IeeTi State of Califomla t CIWMB 181( e )Callfomla Integrated Waste Management Board SurveyForm - Page 1 � 1108445 <br /> 'art A- Survev BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- I ! Inspection Type (Fill one) <br /> Site Suffix: ( 3 ' <br /> l I <br /> { �j J_� LOJ`l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local II I If Referral,choose referral type(Fill one) <br /> Identifier: L � ` �U /�'�"7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name e - <br /> f Inspected By Inspector <br /> L�.QI��.Pi� �I �ei�(_L� I Physical Address13 111 - L <br /> � , Q� I L Ai6- <br /> �C^ &m(Y t(� <br /> ---III L___ w W <br /> Street — -- i I----I—� <br /> I,ns tion Date I G / <br /> P� v � L _ _ � � IQ � I <br /> Cin, S,.,e �!P Cope Time In Time Out <br /> Business Rep Titlei-- --- ' , � `! � '0 AM � , • i� � I 0 AM <br /> fl�l.✓\ r <br /> Ca) C, <br /> v11e1 1 .---' �— -- I--- !® PM <br /> `, !'� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude, - Q Planned ® OTR Q End-Use 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A iHALI,LING,ANDiMAIN -dIREMENTtS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> QQ 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 FXT) <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 1 C•IWMB 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 Violations <br /> O Q Other: --- <br /> Comments <br /> _ pYt/Pi <br /> t:JC.� y1C V tin V1 �A. o�C n <br /> �n�P.-• '�t3 �t�� _�.v es ✓j t G %c l- a 1/70 `f7�S <br /> C� V <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> -_-Business Rep's Si a Phone_N_umber Ins e is Sig fr Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: I orrect: j EjXI A1MI F I.�I E4 ( 1� [2 13 I 62081 <br /> White Cop CIW Yellow Copy:Operator Pink Copy:LEA <br />