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08280040768 <br /> ,,, Waste Tire Survey &.Inspection Report Inspection Report Number <br /> sState of Callfornla <br /> Ggrated IsteManag) Survey Form - Page 1 1 9 - 1 0 7 9 3 9 6 <br /> Calflomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspectio <br /> n Type (Fill one) <br /> Site Suffix: I , JI I 7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -17 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ' y I J 9 - o -CI Z11,-O°,— !=-Dy4 <br /> Physical Address <br /> 12 9� 9 C C'•i- I <br /> Street Inspection Date <br /> L17T gs�i <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title AM ®AM <br /> Q !/ 0 PM 12�d 0 PM <br /> i— --- —_ Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> � : � f' I i <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPSLatitude .L_--�—I�0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude _ I,II- -I- 111 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 111 <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body IS Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORC-'EMENT;STAT�US+ <br /> V > A rHAUL NG AND MANIFEST.REQULREWIENTS <br /> 0 Nonce t- Violation Q Extension <br /> 0 .0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. pliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers +Q eferred/CIW B Enfor ement _ <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Gompl ante No iolations <br /> 0 0 Other: § a <br /> CommentsCo oea' ¢i J�;c4r(,Pw /a (7RI-6.*/337,-717-ol <br /> -3 3 33 } --- ,//��D 9�9S6 —��1���9l0. 4""-f u.�o.�u� ��r, %: <br /> f <br /> Gr' _ <br /> Inspection Form Included: O; 2.Oy <br /> Comments Included: 0' <br /> SiAl <br /> s ep Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKJyMrB <br /> correct: X A M P � E 1 2 3 <br /> ■ WhiteYellow Copy:Operator Pink Copy LEA <br /> I <br />