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08325040066 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state o,calnernla — ■ <br /> Cw" e,(Mew0470.) SurveyForm - Page 1 I1 1088255 <br /> Cali,omla Integ2tad Waste Management Board 9 -- __- -_ _.—_— <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 5! 7 02 T: <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I I If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Complaint Q Educational Visit <br /> Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 2qq C) <br /> 533 Inspection Date LI-9 I / I V I-2— <br /> Time In Time Out <br /> Business Rep Title 'O AM --- -- - - -- Q AM <br /> O PM — O PM <br /> ^-'-/ 1 AA4 AqcI <br /> -Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 50 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' / 0 Active 0 Passenger 0 Generator Q Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GP$ Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet QGovemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ; —A !HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> Q Q <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 Date m / m /m <br /> Q Q 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 NOVorEXT) <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§1B461-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: §.. - — -- -- --- - — -- - <br /> Comments <br /> 01�r:A�_y <br /> —/K^'O_J_SI�-G�f_�- I �.s��Trc Q,� / «��/// ✓�_Cf/ , _ n �)%�� <br /> J <br /> Inspection Form Included: <br /> Comments Included:Q-uslness R re Phone Number Ing sPectojs Signature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BAC C rrect: I correct: l�J E 62081 <br /> XN x a M P L E 1 2 3 <br /> ■ While Co y:CIW Yellow Copy Operator Pink Copy.LEA ® ■ <br />