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4908050403 <br /> Waste Tire SuOey & Inspection Repor Inspection Report Number <br /> State of California <br /> y 9 11 - 11413 0 7 <br /> CFWMB ,steMana e,. Survey Form - Page 1 <br /> califomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I i Inspection Type (Fill one) <br /> Site Suffix: I L(�W <br /> _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local CIf Referral,choose referral type(Fill one) <br /> Identifier: � wt V I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> M_jjs�i <br /> Py Inspector <br /> Pcal �_ �efss — - l$_�— <br /> L-FT - ---- — -- <br /> r— �g I <br /> Inspection Date10 <br /> % <br /> ! 1--`--' - -- -- - 1--- <br /> City - - S!3te Z/P Code J Time In Time Out <br /> Business Re Title f 0 AM II L/ , Ii-�` I 0 AM <br /> 1@PM - <br /> 1_J LO_�J ® PM <br /> Operational Status Tire Type Business Role . Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> Q Active ® Passenger ®Generator ' ®Outdoor <br /> GPS Latitude I i D ®Closed Q Altered <br /> i ' I10 Q Hauler Q Indoor <br /> Q inactive Q Truck <br /> Longitude - i l I i . j l Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantier Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> e .sa�r -,g `i <br /> Part B- Inspection.of Waste Tire Dealer, Generator, Hauler and End-Use Facility. ENFO,RCEMENT STATUS : t <br /> „V A HAULING AND MANIFEST,REQUIREMENTS ,r.• ' ;. <br /> Q Notiwbf.Violation QF�rtension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �h: <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 'r ` �r <br /> Compliance Deadline 11 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> wi <br /> Q Q 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements 'Dar = / V,f <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> .$ (Requ6ed forQ Q 14 CCR§18459.2.1 -Submittal of Comprehensive Tri Logs within 90 days NOV! <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§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 a � . <br /> ®,Incompliance No,,,Violations• <br /> Other: §L � ( * .� '� -yam.• <br /> Comments <br /> �e� �o_vn M P�►'1, 'P <br /> Inspection Form Included: 0 1©C( - �p IC <br /> Comments Included: - Vpls/Signature <br /> ` _ _f -�3 <br /> ® BusinesPhone Number Ins t r' gnature Phone Number <br /> INSTRUCTIONS ON BACK Fqorrect: Incorrect: X ( 1 9J E�X Ajj P L E 12 3 62081 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />