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08157050020 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of Callfomla <br /> C9-t*U-11hi01!01) Survey Form,- Page 1- L 1 3 - 1 0 7 9 2 2 6J <br /> CWMomla Intapotad Wnle Namyamant BoaN �. <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> SlteSuffix: I/ 5TH / Q Routine Q Re-inspection Q Referral 40 Observation <br /> Local LIf Referral,choose referral type(Fill one) <br /> Identifier. p ,t f� Q CHP-Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Businesses or Facility Name' 6� A Inspected By Inspector <br /> Physical Address <br /> Jn A �53� Inspection DateEoE5 <br /> / �S <br /> -u' "t _-_.__ Time In Flow <br /> Time Out <br /> City State ZIP Cods _ <br /> __F_1:L_ <br /> Business Rep Title ,r- 0 AM AM <br /> ___i-- I- - 0 P <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) (Fill all that apply) <br /> 0 Active Q Passenger I.Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> - .0 Q Inactive Q Truck <br /> Longitude - ' I j I Q Planned •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 40 Other LN�d tti_ I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMEN STATu <br /> yfffllffiffiljS IR M <br /> Q t on <br /> Q Q No ice Of VioleEMension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co pliance t)eadline <br /> PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 o <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!C-IW MB 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 1 Co Ili n- - No Violations <br /> 010 1 Other: § <br /> Comment <br /> is ��SG►V.J�t'e_a�- i k.�'�+1-�-/���-m 4d+�t.-.-��jF,,��G,Gr11/-r-- -W"� -^f <br /> Ibf9's-�'•_/_Irlr-!I�.�t� C6w..v� .w.a1i'�q,e�� .-/Vic.-at...� �f'►��.tf'/y�T��� �'�.{ <br /> cam-- N �r/Yitli.. ✓M /—��CL•...-'� A r�V_t�t1� .'�.L._ !/eti:y� -• r- <br /> Inspection Form Included:Q <br /> Comments Included:Q _ 4ei8 46�Z <br /> Busi ss Rep's- tature Phone Number Inspector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK7orrecrtIncorrect EX A IM P L E 2 2 3WhfteYellow Copy:Operator Pink Copy:LEA ® . <br />