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09259.040642. <br /> 4 Waste Tire Survey & Inspection Report ; Inspection Report Number <br /> ere. <br /> State of California <br /> r�iaa <br /> Cgrated Waste <br /> Survey Form Page 1 1 7 - 1 0 7 9 .3 9 4 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . . . <br /> TPID- 3 -7 / f Inspection Type (Fill one) <br /> Site Suffix: 7 Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S LCLjL 11012�r-Ct Q CHP Q.CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name <br /> /�° Inspected By Inspector_ <br /> �� ku•tom <br /> Physical Address _ <br /> 3 3 3 3 G ,4,r <br /> Street W <br /> I ,., I ^ ,/�� � �3�gi Inspection Date <br /> City -T" State ZfP Code Time In Time Out <br /> Business Rep TitleM/ 10 <br /> AM f C/ / AM <br /> a O PM / O r / I 0 'M <br /> Operational Status Tire Type Business Role Storage Type <br /> i L/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> t r' 7 <br /> ®Active ® Passenger 40 Generator Q Outdoor <br /> 1— j • <br /> GPS Latitude. O <br /> Q Closed Q Altered <br /> d <br /> Q Hauler Q IndoorJI—L10 <br /> 0 Inactive Q Truck End-use Q ContainerLongitude Q Planned Q OTRJ — • _ <br /> . <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 i Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other l <br /> Part B-'Inspection.of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 7A H U INC D NIF ST .EQUR E TS <br /> otice <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NUf Violation Q Extension <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle . <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IE / 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 or E)CT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/C-IWMB 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 Gompllance - No Violations <br /> Q Q1 Other: § <br /> Comments �- t V.-r94ee_TT aL <br /> CO 9l�6-r /GtQ'r�,a`G ' GAJ, Y`+ C! '/"�+ l4st �s��e • / L1Ci�ei" ��// /�4-GG�C.d 7 <br /> C/ - <br /> !n'/ � <br /> Inspection Form Included: Q l 210 q) <br /> ✓r y�g—�3S <br /> Comments Included: Q • - - —y—��SsZL� ,v <br /> us R ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orree neorrect: s2081 <br /> � EXAMP ;L�'���Z �23 <br /> . White py.CIW Yellow Copy Operator Pink Copy.LEA <br />