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09.280444162 <br /> E- , Waste Tire Survey& Inspection Report. Inspection Report Number <br /> State of California <br /> gratedW Waste <br /> nage). Survey Form - Page 1 � I 1 - 1� 0 l 9 3 9 7 <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID- In31 spection k!d - D / Inspection Type (Fill one) <br /> Site Suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �Q7i O CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I .��o�lG�� l� KCO.�-i► /rc�fs.tla/ �4 z.�c.. _ /(/�7�/ 'L/� <br /> I <br /> Physical Address . 1 3 9 I S'+uQ/��i•—/✓/�V� <br /> 300.3 <br /> Street A / <br /> Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep Title D d O AAM [ZjD] : r� O AAM <br /> PM <br /> PM <br /> Operational Status; Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l (Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Q Active f Q Passenger Q Generator Q Outdoor <br /> 1 D S Closed Q Altered <br /> GPS Latitude . �`--I--I_—I � I Q Hauler Q Indoor i <br /> --T] <br /> _. O Q Inactive Q Truck <br /> �- I <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> p New Tire Dealer Q Auto Repair p 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 I <br /> Part B-Inspection of Waste Tire-Dealer,Generatori Hauler and End-Use.Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENT <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Ytolation Q F:xte sion <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance t)eadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 0 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 OV or <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 Com liance - No Violations <br /> Q Q Other: <br /> Comments Q�?Q�¢ e.� n aJ a-.0✓e'w V`'� 4 GLQrtJ a%/7 YJ� <br /> L177— . 1�f17) /f/ 7S <br /> re <br /> Inspection Form Included: Q <br /> Comments Included: Q — <br /> Business Reps nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON'BACK �orrec Incerrect: X .A M. P III i 1 '2 3 <br /> Whit-1777 <br /> hite py.CI Yellow Copy:Operator Pink Copy LEA <br />