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0$262349577 <br /> iiiim Waste Tire Survey & Inspection Report Inspection Report Number <br /> LIN State of Callfernla Survey Form - Page 1 I 1 1088196 <br /> CIWM81at(New nage y <br /> California Integrated Waste Management Board J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f 1 7 �I 71 <br /> I �I �� O / Inspection Type (Fill one) <br /> J <br /> Site Suffix: I 1 ®Routine O Re-inspection Q Referral Q Observation <br /> Local �1_ If Referral,choose referral type(Fill one) <br /> Identifier:,/ J Q,q�r�N (,fa�r.��-v1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �T Inspected By Inspector <br /> 149AS4 �e 3 � _ � � C) iI ' <br /> Physical Address L? <br /> Attic 4AZE') <br /> // agg W- ✓ i. <br /> Street <br /> 95 3 <br /> Inspection Date <br /> �-�� V C� <br /> City / State ZIP Code Time In Time Out <br /> Business Rep Title I O AM O AM <br /> II• <br /> I------u O PM I _ _ O PM <br /> -01/AIJ Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) .(Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r 1 r <br /> i Active Q Passenger 0 Generator Q Outdoor <br /> 0 Altered <br /> Closed <br /> GPS Latitude I Hauler 0 Indoor <br /> ___— -- -- - — - Q Inactive 0 Truck' <br /> —. —,O <br /> I Longitude planned Q OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture O Shredder 4j Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT S1TilA7US <br /> 12"A IHAULINGIANDIMANIF�ESJT/RE0WIRE.MEfITt$ 0 Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 2111110 <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requited for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-ompllance - No Violations <br /> Q Q Other: §, n n <br /> Comments ¢ <br /> �;1k Iae <br /> j K�,o//�� ��C.,•.fin—f�.e�_ C!S Jc,n wu� aw %�e�.� V Gp%t�.4e� 7Y'/e <br /> �q-l`i aN S a/L_ 4Qj_4 ey.r,c -JC,7-" J <br /> I <br /> Inspection Form Included:Q �� C7-- <br /> �-Vn9�,, <br /> Comments <br /> Buslnes{/Ftep'ty Signature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK C rree I�Ll orrtect: JEW-JEW1t12Ig1 62081 _ <br /> . White Cop CIW Yellow Copy Operator Pink Copy:LEA ■ <br /> L <br />