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08066040008 <br /> Waste Tire Survey & Inspection Report. Inspection Report.Number <br /> Ctatae"a°`ernla SurVe Form - Pa ' e 1 1 3 10 7 3 4 1 0 <br /> c,rat 181fallow lie y g <br /> Califomla Integrated Waste Management Board ,J <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` 1-71-71 .5 O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ''''nn If Referral,choose referral type(Fill one) <br /> Identifier: a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> I �'l Al c . <br /> Physical Address 3 ( Q ( LJ /-pL(Z �i� <br /> aoo s w Yom fi� ire, l/ <br /> Street !' <br /> I ✓/t/,t<,faid�Ca C4 9533!( Inspection Date <br /> City State Zip Cod- Time In Time Out U <br /> Business RepTitle ���y�� O AM O AM <br /> ta <br /> y n I4 r_YI L- � `' m m0 <br /> PM m O PM <br /> Operational Status Tire Type Business Role -Storage.Type - <br /> ( (Fill one only) (Fill all that appy) (FIII all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE)' <br /> 'r f _To Q Active Q Passenger Q Generator Q Outdoor <br /> I- —1' O Q Closed Q Altered <br /> GPS LatitudeLl <br /> Q Hauler Q Indoor <br /> O ®Inactive Q Truck <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 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND-MANIFEST REQUIREMENTS' <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste The 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m <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 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/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 Compliance-- No Violations <br /> Q 1 Q 1 Other: §N-�-)- / �( ,L /y " <br /> Comments t7�./LAX l►�l C�Z��j . CiC K /�/ OSS D + N t71�1 cJr r_ �l✓� <br /> 5evJicose /4l( serjice done Ap �ifi-e afi 6 /�'iCa f <br /> _" l s. Flo ✓iaL f'- <br /> InspeetionForm Included:Q .09 j <br /> {9j <br /> Comments Included:Q . <br /> Business Rep' Ignature Phone Number Inspector's Sig' ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X& � � ■ <br /> E. xAm_FLE x '23 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />