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OS05609065� <br /> «€ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State-f 8asteMaea0e Survey Form - Page 1 13 - 1 0 7 3 4 0 2 <br /> Califomla Integrated Waste Menagament Board <br /> Part A-Survey OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r /101 <br /> O 0(^ of^ - O I Inspection Type(Fill one) <br /> Site Suffix: l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O� ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name UInspected By Inspector <br /> L <br /> AlmMa•n—I- �.ti5t� Cr,��- q FoT Physical Address 1 _ <br /> Abo <br /> " Wdg-n W" I <br /> Street <br /> L S�c r nn L7 ��5Inspection Date O O p g <br /> Cit—__y (f I State Zip Code Time In Time Out <br /> Business Rep Title 0 Am 0 Am <br /> m'm O PM IT-1 m O PM <br /> _ Operational Status Tire Type Business Role Storage Type:. <br /> Tire Count(Whole/PTE)! ( f� 711 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r I I r �.-1 ] ®Active (0 Passenger ®Generator ®.Outdoor <br /> r l I O Q Closed Q Altered <br /> GPS Latitude W Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - F Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®: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 <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 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FH / M / M <br /> Q Q. 14 CCR§18459.1-Tire Program ID Number from CIWMB I <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required forNOV 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 0 Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> L14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In ComplianceNo Violations <br /> Other: § <br /> Comments -Kl n Q <br /> G�fah S i� V r r"`t aL S,P AaJ OF <br /> les res �tl� 7 t►-e ae�oSs r-eat• Ab <br /> Inspection Form Included:Q <br /> q q%-Fj ? '7 a-996 <br /> 96(J <br /> Comments Include ••Q Business Rep's i'nature PhoneNumber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:X(�p E X Mj P L 4 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />