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09098040037 <br /> ,,.]Waste Tire Survey & Inspection Report Inspection Report Number <br /> 1 <br /> u; 8bla or anromm I 1 - 1088374 <br /> CIWMa,etlNaw WIU Survey Form - Page 1 <br /> Cellfomla IntegnLd Warta taameemenl Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �I ►► �� Inspection Type (Fill one) <br /> Site Suffix: Q U ( O Routine 0 Re-Inspection Q Referral ®Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier J�O/i;n 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> aor�Facility Name Inspected By Inspector <br /> so ��FJ WQPhyscal A diiQ hlE3 <br /> g'C <br /> � 6coa, Dr I <br /> Street Inspection Date <br /> T-ra- _ -)I Time In Time Out <br /> Cih/ State 11, Coda <br /> Business Rep Title �F.^ gP AM F_�1 r ®AM <br /> �I' 0 P / I �I ' C2 O 0 p <br /> Operational Status Tire Type Business Role Storage Type <br /> o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(VlfholelPTE) <br /> r ° Q Active Q Passenger O Generator Q Outdoor <br /> GPSLatitude ° ®Closed Q Altered O Hauler Olndoor <br /> D 0 Inactive O Truck <br /> Longitude — O Planned O OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader O Dismantler O Tire Derived Fuel <br /> QUsed Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture O Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O ---- — <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years ' <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 1 Other: § __ (� <br /> Comments Fa d1 !w I p v f_— Qlti�– o� •'��- 1% �rQ , � (ORP- <br /> �t.az�o1_. (2-10 ��S-Fa*g rre <br /> Inspection Form Included:Q 4 ajej � M �_^ 4/w"99tGt� <br /> Comments Included:Q r� v W I tY/C <br /> Business Rep's Signature Phone Number Inspe or Sign�ur. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct.- Incorrect:�(� � E X A P L E 1 2 3 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LFA ® ■ <br />