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08262040541 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ste l <br /> ■ <br /> :WMBIS,(N"o.Iw) Survey Form - Page 1 I1 1088238 <br /> Callfomia IMsgratnt Bwn7 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I _S _7 � � l � � O � Inspection Type(Fill one) <br /> Site Suffix: I ` I /+ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local S 4r\ TO Q Lll n COUT t If Referral,choose referral type(Fill one) <br /> Identifier: q y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> M01 <br /> Physical Address <br /> LXris'tic►r� L_uCQS I <br /> I 1412 V,1.-1�oscr+nite—/4ve. _� <br /> Street Inspection Date <br /> —M.alntec.ox__ CA 9533-1i <br /> Cray State ZIP Codi O AM Time In Time Out <br /> O A <br /> Business Rep Title i ��, M <br /> T OPM j OPM <br /> - -- = — --- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fin all that apply) <br /> r r �'O 0 Active Passenger 40 Generator .0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> -0 0 Inactive 0 Truck <br /> Longitude _ ! _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fin all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other 4 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> A11H '111l ERUIREMENT <br /> otice lolatlon 0 Exten on <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of fires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 § e9 Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required or NOV or FXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompllan No Violations <br /> 0 0 1 Other. § _ ( <br /> Comments �O <br /> t.�!�VVA tl <br /> _trA6�AC. �Of1_ C OLr_iY1L� s _�4 OWIn was r1.Q3l <br /> la: <br /> �p�rnx�O�asi���i„sed -��res ofoce_�a�-si-t—���es_ore�-emo�r�ed_w�– <br /> er►� y_ceaGlQOr�S.FoilCiliy—�Ses Lak iy� -TirB �er .�aS�e -4►re rG�oV �. <br /> CLY' �Joe. s v i etaed_. talo N 1 Oj Q�lo_RS_O!�4� a�concern nof��. <br /> Inspection Form Included:0 ^ [204 <br /> Comments Included:0rs Signature.r�6 3ler <br /> Bu ss Rep' nature Phone Number In Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: ncorrect: F X A M'P L E 1112131 <br /> ■ White y.CNYM Yellow Copy.Operator Pink Copy.LFA ® ■ <br />