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0921004029.2. <br /> Waste Tire SuSey & inspection Repor Inspection Report Number <br /> ItIHI2 State of California <br /> wi� T 1088^ ^ ^ <br /> Cbrated asteManage Survey Form - Page 1 11 I8 8{ LJ{�•.�J <br /> California in Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I �� - � ® Routine Q Re-inspection O Referral Q Observation <br /> Localv r If Referral,choose referral type(Fill one) <br /> Identifier: � J OQ V_0�r"`� Q CHP O CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name v Inspected By Inspector <br /> !V ormaii �OGk Bri�ls� Ca� , <br /> Physical Address <br /> ao&C N. W115um W'g , <br /> Street <br /> StoG��D 5�;205 Inspection Date <br /> City l State ZIP Code I Time In <br /> i � Time Out <br /> Business Rep Title —T QAM ---O; J � <br /> IQ AM <br /> 3 O �® P ® PM <br /> ----- Operational Status Tire Type Business Role Storage Type <br /> The COUnt(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> Latitude <br /> Q Closed O Altered <br /> GPS I Q Hauler Q Indoor <br /> .0 O Inactive O Truck <br /> Longitude Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer ® Auto Repair Q Trucking Fleet 0 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 I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> OUR MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Ext <br /> O Oension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 EXE <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In C-ompliance - No Violations <br /> Other: § <br /> Comments 01&f Lai / 'QST fi Um <br /> 6,,Vic:— 0 —►moi—kuklfS `7'0 S kUj� DF (,Aj�5�'2 t2�eS Q�oS�' <br /> 1�1 f SUy) warn T% es irL. OwAJ .fie-S d' ay- It°sS Alp V/0 <br /> �c��S hDt�c�o ��OV e--,-b - a " lei IS DvI Vl�a i <br /> Inspection Form Included: 0 v�9 <br /> Comments Included: Q - —B$7 <br /> usiness 4p's _ ture Phone Number Inspector's ignature Phone-Number <br /> Corr et: Incorr62081 <br /> INSTRUCTIONS ON BACK ect: . <br /> � XAAhP L E � 12 3 <br /> White Copy. IW Yellow Copy:Operator Pink Copy:LEA <br />