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08255040026 <br /> jMWaste Tire Survey & Inspection Report ._Inspection Report Number <br /> ctate"s 10te+ No.ovali i Survey Form - Page 1 1 6 - _1 0 7.9_3_0.3 <br /> crvvMe .w <br /> c"11""le Inl.grat d W.W.Mar-gement Board --_- <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Tsi • / / / 77 y 0 , I Inspection Type (Fill one) <br /> Site Suffix: IS Routine Q Re-inspection Q Referral Q Observation <br /> Local n H Referral,choose referral type(Fill one) <br /> Identifier: J�� ���w7r Q CHP Q CIWMB Q ComplaintQ Educational Visit Q Other <br /> Business or <br /> o,rr FFaacility Name Inspected By Inspector _ <br /> Physical Address /�T I F/To <br /> Streets p 9 g <br /> 9 5:,2D_7 J Inspection Date <br /> City' ]`p Slate f(P o Time In �1 Time Out <br /> Business Rep - - - Title AM. .� / @ AM <br /> IO 1 O PM 1 -_JL� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> Tire Count(Whole/PTE) r + �� <br /> is Active ®Passenger 0 Generator Q Outdoor <br /> Latitude i <br /> !0 Q Closed Q Altered <br /> GPS Q Hauler !Indoor <br /> __.-!O Q Inactive Q Trude <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer •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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> F S U REME <br /> Q Notice Of Uiolatio Q E•to slon <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliant Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (Req it fo NOV r EXT <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Lags for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers erTecJ1dulWM8IjE7FTforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§123462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �I Co pliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> .,&, <br /> e ua� <br /> Inspection Form Included:Q 20! <br /> Comments Included:Q <br /> Busln s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK reef I torr E XJAIMIPILIE1 1112131 <br /> 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy LFA <br />