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08157040114 <br /> L= , Waste Tire.Survey $ Inspection Report Inspection Report Number ■ <br /> a arate of wmsleleomla Survey Form - Page 1 18 - 1 0 792 <br /> 0 6 <br /> clwae tee(New octal <br /> catflomia integrated-ate Management Boats <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- / � � w � � � - O / Inspection Type (FII(one) ' <br /> Site Suffix: . L Q Routine Q Re-inspection Q Referral 0 Observation- <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: JQq if,VQ CHP Q CIWMB Q Complaint Q Educatlonal.Visit Q Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> I��N i O Q <br /> (Physical Address I -/ 0 / L4.. <br /> 3310 A ;N_4Le._,_4-v ,l - -- -- _YTTAAAMKK <br /> (Street <br /> STInspection Date <br /> os�cY! C� 952oG <br /> City —Mate�P ode Time In Time Out <br /> Business Rep Title O AM0 AM <br /> M- OPM [T-1em 0PM <br /> 7An1_ �i:-6 It— -- - -ta,e tL -rs <br /> -- Operational Status The Type Business Role Storage Type.. <br /> Tire Count(Whole/PTE) ! (Fill one only) (Fill all that apply) (Fill all that apply). (Fill all that apply) <br /> r ' 40 Active Q Passenger 40 Generator 0 Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> —_ O Q Inactive 0 Truck <br /> Q Planned Q OTR <br /> Longitude Q End-Use Q Container <br /> 9 - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4j Trucking Fleet Q Government p 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 0 Other LlQaad 0i_/ �F�2, 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 Q Notice Of Violation Q 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 /> Q Q PRC§42956-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Data <br /> m / 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 forNOV or F_XT) <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. § <br /> Comments <br /> _/'�+u'• a�-�!S_r"s -��,�-r_i��f a.c.c/�_¢._=�o��a_/•�r�c�vsa_2 <br /> Coal cg,�,1/S A.1 £e0: <br /> Inspection Form Included:Q 287 <br /> Comments Included:Q '-�" GZ �G <br /> Business Rep° gnature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc : Incorrect:N(1� V I I ElIXIAM1P I L I El I 112 131 62081 <br /> ■ Whit Copy CI M Yellow Copy.Operator Pink Copy.LEA ® ■ <br />