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cgas2aq©gas <br /> rtr. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> state CRVM rcal@omla04104) <br /> I 1 - 1088192 <br /> caliromla lrrtagnMad WasteeManagament Board Survey Form - Page 1 <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- 121 " <br /> loll <br /> /) - Inspection Type (Fill one) - - <br /> Site Suffix: a 12 "� 0 Routine Q Re-inspection, Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �RN 3pq�'� C, ;rl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I T -I-V 3 9 - t+ o <br /> Physical Address <br /> 38�D L= r_y,oa ► , <br /> I W�os�r►�_�_�-G/��� I <br /> Street Inspection Date O 6 / l r / 5 <br /> I T).ro_P G,e} 95330 , <br /> CityStatim Time In Time Out <br /> Business Rep Title O AM O AM O <br /> i !' PM i _IO PM <br /> y - - Operational Status Tire Type Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that•apply) <br /> Tire Count(Whole/PTE) <br /> r 0 Active Q Passenger 0 Generator Outdoor <br /> GPS Latitude - j - - _- 1O Q Closed Q Altered <br /> j I, 1 Q Hauler Q indoor <br /> — —'- -' I- -- Q Inactive 40 Truck <br /> Longitude Q Planned 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 <br /> I I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility IIIIENEIVROEMENji STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Extension <br /> Q Q <br /> PRC§42351-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 <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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q i Q 14 CCR§18460.2-Manifest System Requirements for-Registered Waste Tire Haulers Q Referred 1 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 In ompllance - No Violations <br /> Q Q Other: § <br /> Comments D At °''� /�s,� /+ w /� / /1/�Jli1l�► Lt�A,,d�1o��� <br /> 400*"4_ Tim at.e �? `. , a.�t,:r;6& <br /> U01t��) .-�D Ivo ✓ice �u a n r G^►eh a s A)%-M D.� <br /> Inspection Form Included:Q C163 <br /> Comments <br /> Comments Included:Q <br /> Business Reps Signature Phone Number Inspectors Signature Phone Number <br /> - - -- - -INSTRUCTIONS-ON BACK C rrect: ncorreet: - -62081.. <br /> ■ EX-iaM.p. � .E - z s <br /> o While .CNV Yellow Copy.Operator Pink Copy LEA <br />