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08227040057 <br /> Waste.Tire Survey & Inspection ReportInspection Report Number. <br /> crwmefCa(Ns. Survey Form.- Pagel I 9 - 1010880 <br /> clwMe tat(new ouaq <br /> Callfomla Integrated Waste Management Boats . <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - ' 'L ,1 © Inspection Type (Fill one) <br /> Site Suffix: `T 7 Routine Re-inspection Referral <br /> - � Q P Q Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Idantifler: �/}�( e�0i4�R,w ju C, Q CHP Q CIWMB. Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (JJ ((,r//� Inspected By Inspector <br /> _ r � <br /> Physical Address f4A&o <br /> I 3532 C <br /> Street /] <br /> -57Z� , / ! 9 52vs Inspection Date <br /> City State Zlp Co e Time In Time Out <br /> Business Rep Title O AM O AM <br /> e-l m m O O PM <br /> PM m m <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE):a (Fill one only). (Fill all that appy) (Fill all that-apply) (Fill all that apply) <br /> ' ' Active 0 Passenger Q Generator 0 Outdoor <br /> o I Q Closed Q Altered <br /> - GPS Latitude m• Q Hauler Of ndoor <br /> O Q Inactive Q Truck <br /> Longitude _ I I I I_ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ��� <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader Dismantler Q Tire Der ved 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 ENFOR�C�EMENT STATUS <br /> V A f HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 pate m / m m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID.Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required(or NOV or Dc7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments D <br /> y— _il_s Aae�t 2 t' a icyiG ��,s <br /> — — ;�,''1v_ .C.CP/l •�a P Jy,cr,� � 1 Sr4.0 �o be S_eleo as tas <br /> �__`�'"��'-�@ ---{�•� "'' —�i�le TPI i„baex;Vo�'�t ( <br /> Inspection Form Included:Q fl <br /> '•'-3 4 <br /> Comments Included:Q *RetilgnirtwileInspetors Signature— <br /> Phone NumberPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect: In, YX jEjXjAjMjPjL1E1 1112131 <br /> ■ White py:CIW Yellow Copy Operator .Pink Copy:LEA <br />