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08227040059 <br /> Waste Tire Survey & Inspection Report Inspection Report Number � <br /> cM1YMsi81(New 04/0!1 <br /> rwta of arrernia Survey Form - Page 1 1 4 - 10 7 3 4 5 2 <br /> MB ' <br /> CaINomla Integrated Waete Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• / r /T D / Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 7 7 { <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local _OA � If Referral,choose referral type(Fill one) <br /> Identifier: J � q ��� Q CHP Q CIWMB Q'Complaint Q Educational Visit Q Other <br /> Business or Facility Name `^�" <br /> Inspected By Inspector <br /> i_ I -Physical AddressIN!] <br /> 2-030 A-,,To R42 A vie #f //0__j <br /> ""Tff���YYf ttt��� ryr1KU�Al <br /> Street <br /> Inspection Date <br /> 7V <br /> 6-1y l� State ZIP Code Time In Time Out <br /> Business Rep Title F1 Q AM Q AM <br /> ViLro2 Ij�q �t.—_ —J OPM m'm OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> t i i r 1 I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ; <br /> Tire Count(Whole/PTE) r <br /> Q Active •Passenger Q Generator 0 Outdoor <br /> Latitude W 1 1 1 10 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 0 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 !-Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility NIENF.0RCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice <br /> Q Q Of Violation Q E tension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§19459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Req /o O orF]C� <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/GIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> —�5—,�:/_LS rN�cw.a..�`�+'¢o�--r-a r L�ss_�D �!r-c Plos. .�.t,(�-�T i/_•�e- <br /> TP.=D # _ <br /> Inspection Form Included:Q _ A <br /> C7_0 4'5 <br /> Comments Included:Q <br /> slness Rep' ign lure, Phone Number Inspector's Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK 7�� <br /> FIV . <br /> correct: JETX a M P L. 1 2 3 <br /> ■ While Yellow Copy:Operator Pink Copy LEA ■ <br />