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08248050007 <br /> AI. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> La BtataCalifornia I 1 - 1088177 <br /> CIW0*1 (NawOUodl Survey Form- Page 1 <br /> California Integrated Waste Management Board <br /> 'art A-Survevmig BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I O / /�( O Inspection Type(Fill one) <br /> Site Suffix: j I I 11 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I , If Referral,choose referral type(Fill one) <br /> Identifier- �0 J ,,,`� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'V7� Inspected By Inspector <br /> Physical Address _ 41 ��D ____� <br /> Street <br /> I _57z� ^A I Inspection Date Q <br /> City C� Stato 7ZlPPCCoddee Time In Time Out <br /> Business Rep Title F-7 —I O AM 7 O AM <br /> �f O PM I j'I J O PM <br /> Operational Status Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 1 � � <br /> 9 Active Q Passenger 0 Generator ®Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive 4DTruck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFOr ,cr­w o,., o ATOS <br /> V A ,Hl W1W Ili NGIFAND MANIFEST REOWIREMENTtS <br /> 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 I Q PRC§42956-Registration/Decal in Vehicle <br /> 10 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 (Req fired for NOV or EXT) <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 GIW MB 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 /> Q Q Other: §, <br /> Comments <br /> OM-Ijr <br /> arc a/�•�_i, r�4G_4—� >�t_l�p�.� �+'�t f q� /�).�..�� re�:S�- fLfr A6�- <br /> — a�.;L� �-_ a,.t��J,... Lo c_sl.d.., �,.A S�AA.ti,s/��i�1,�,%s1�� ��- —L�.a�►�.. <br /> i tP L D is iele_t ✓_�- A�/ Tiic I.�.ba K Vi f l W-7 /1r•4,,,A <br /> Inspection Form Included:Q .�,.�,l 4!t_ci <br /> Comments Included:Q T 3- <br /> Busi s s Si natLre Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co reet� ncorrect: I0XIAIMI P I L I EI 1112131 <br /> ■ White Cop CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />