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092SS040588 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CFWMI f.81(New <br /> Survey Form - Page 1 12 - 1 0 7 9 3 9 8 <br /> Cgrate 181(New 04104). <br /> California Integrated Waste Management Board . <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: [/Tal, J 'z/ 1 ,:6]11 - O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier. ��,rL c/C7Q �OrC.t i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ W <br /> Business or Facility Name Inspected By Inspector <br /> 11" <br /> Physical ddress 9 l J11,9.Q-oyti%lDv:A <br /> i 3,2 <br /> Street <br /> Inspection Date O / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ® AM 10 AM <br /> [�Ii <br /> O PM I O `" D 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> t •Active ® Passenger ® Generator ® Outdoor <br /> f O Q Closed Q Altered <br /> GPS Latitude I I •I ! Q Hauler Q Indoor <br /> �--1-- L ---- Q Inactive Q Truck <br /> -T� FO <br /> Lon Rude - I Q End-Use Q Container <br /> 9 Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body • Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A i 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 Date <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 for NOV orEXl) <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 I 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 �,,Q �'�•�,o.�-� ��"� C�-td �//__ fr���`� Way l�p�t�( <br /> C n� / <br /> L/ � rS Quo/ rS VI"e,-Co� / _ /QD LjCaQ/ <br /> 1 7-ry <br /> Inspection Form Included: QI _ // <br /> Comments Included: Q - — <br /> -�`/--AZO y�, ij/ <br /> u ess ep's S' nature Phone Number Inspector's Signature . Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect: ncorrect: (P_ qjjE�XjAh4 F lr l Z 3 <br /> ■ White Cop .CIWMB Yellow Copy:Operator Pink Copy LEA <br />