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Q822704©1.96 <br /> w <br /> Waste Tire Survd' A Inspection Report Inspection Report Number ■ <br /> St.b.of C lft,nia <br /> Cignted Waste <br /> nageM04) Survey-Form - Page 1- 17 - 10 <br /> 1 0 8 7 9 <br /> California Udpntad Wuta Managamant Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details •: <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' f O Q D 9 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 - / If Referral,choose referral type(Fill one) <br /> Identifier: �TL <br /> SATr./fin.�( (rOtM/T Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> KS klA3_a-yt 13 cj - 1 0 � i .ti.�� NA,e.t��•l� <br /> Phys cal Addrcs <br /> Street <br /> Inspection Date <br /> 79A C_q 1530, <br /> City State ZIP Code Time In Time Out. <br /> Business Resp a Titlle0 AM 0 AM� <br /> m0PM m m 0 P <br /> _ Operational Status Tire Type` Business Role Storage Type <br /> ( one only) (Fill all that a9 (0 Q <br /> all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE (/J� <br /> Active Passenger <br /> Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m• Q Hauler 0 Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste.Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A U ING MA I EST RE jUI 1REME S <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice CM Violation Extension <br /> Q <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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14.CCR§1845921-Submittal of Manifest Forms and Tire Trip Logs within.90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Fors and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§.18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C 11111111 BI IEnforcement <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: §/,1 <br /> Comments 1 _-J/ (�Ni %NSQQ ioY1 J>r % y Gf'aT4 / - �/`of.Ji_Waw_ NOMl <br /> � �/C .C,.' ..ia.,.� C kJ/ 5 /}S �'�..�, /'•r.'tf f S'�-.�..,�!!//______!�`r�< ��aA.,.,Q._. <br /> 1 <br /> (�cs In. -S <br /> J. <br /> Inspection Form Included:Q CL <br /> Comments Included:Q — �6S <br /> RQ�e�Z- <br /> Busine ep-s.Signature Phone Number Ins ctoes'Signature Phone Number <br /> INSTRUCTIONS ON BACKC rrect: Incorrect: E X a hh P L E1 1112131 .12081 <br /> ■ White py.CIW Yellow Copy Operator Pink Copy:LEA ® ■ <br />