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08221044148 <br /> n°- <br /> Waste Tire Survey & Inspection.Report Inspection Report Number ■ <br /> �n st,f.of c,lnoR,m <br /> st t' c'lff arlWW, Survey Form - Page 1 1 6 . 10 7 3 4 4 6 ' <br /> califomla Int•grat•d W-1.Manag•m•nf Board - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O 2 ' 1 / © / Inspection Type (Fill one) <br /> Site Suffix: ,�� 64D Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: f✓ /' <br /> a9S�• lou-'^T�j Q CHP Q-CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� f/ Inspected By Inspector <br /> L_ 4W_e r c-ak is 3 g <br /> Physic - a <br /> Physical Address- AJ <br /> L Aw 1 f- 2D£ <br /> 1 555 -- <br /> Street CA p' <br /> Inspection Date <br /> dy State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> Operational Status: Tire Type Business Role Storage Type <br /> �' j II (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> I - lit I I 4O.I 0 Active 0 Passenger 0 Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GP$ Q Hauler Q Indoor <br /> l O Q Inactive Q Truck <br /> Longitude _ L Q Planned Q OTR .Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 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 /> O service Station Q Hauler Q Agriculture Q Shredder Q Other l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATLU$_ <br /> y 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/Decalespnsibl Entities <br /> Vehicle m m <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (R wired for NOV or FXT) <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 )1F;refFr­red111CIWMBl1lIEFforcement <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 •In C-ompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> `' � o ---i�o�L«f,_aY*—�. �� •---i2��(,/.,�•'J �r•a .aorto' .i...:.. <br /> —/T�c.s',C a,'d�—ri"d-�J L�.J ?f�- �a�•pd.�A.6 �.t<--� ���s�...�0 �/rL 1,..�-�a•. - <br /> _rrmcLu�'_�a-�su�cwc.c�. � -�/••al.►�%e�.,s oA_G„cci._,..r��r_�' <br /> Inspection Form Included:QQ 7 <br /> Comments Included:Q <br /> Busine p's ignature Phorie Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK C1�"- <br /> neorrect: E X A M P L E 1112131 62081 <br /> ■ While CoYellow C <br /> opy.Operator Pink Copy.LEA ® ■ <br />