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08128040761 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberStme ■ <br /> CIWMB <br /> SurveyForm - Page 1 1 3 - 1079440 1 <br /> CIWMB 181(New n.g. <br /> CalHomla Integretad Waste Management Board <br /> 'art A-Survev. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection l Z a I I ` I p I Q r Inspection Type (Fill one) <br /> Site suffix:. I II T / ®Routine Q Re-inspection Q Referral Q Observation <br /> Loral If Referral,choose referral type(Fill one) <br /> Identifier: y\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility 11�me Inspected By Inspector <br /> IL,I I,.�,,.I_W {k s I 2�Q <br /> Physical Address J 1 - loll <br /> I Lf <br /> Street O 3 Z S G <br /> 1 �;/� Inspection Date <br /> City _L.00t __I,n_4 gz_qtate oC d AM 0 AM <br /> (Time to Time Out <br /> Business Rep - Title I=: 0 PM LLI'm 40 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r 1 Z ;D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude i I <br /> GPS •i_ _i—. __._I� Q Hauler Q Indoor <br /> _-- —,O Q Inactive Q Truck <br /> Longitude - I I I I I I I Q Planned Q OTR Q End-Use 0 Container <br /> l <br /> Business Type (Fill all that apply) <br /> •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 Q Other I l <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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 FX7) <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/CIWMB 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 A In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> �la,,�h �• y.S_ra.��,tk._ - -�+.s-s—alc.-t<.-. _L� _U.sc� Lak:n <br /> r1f_;.rL—f v,r_ rc, "��tt.r�.o c�.�2 C a�C,clvla a_(3-yam mks ., + �, <br /> p_tcs l_ X17 —it<i.w.r.r�L U1 lJ CLI► t-rf — Y1— 17 J=S <br /> Inspection Form Included:QI <br /> Comments Included:Q- w �--� 4/G�—Dt±Z3 <br /> /,business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK CorrectAp Incorrect: (�V' q I EIIXj A jjMI P(;L 1 E( 1][213 1 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA �� ■ <br />