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■ U80870N umber ■ <br /> 0025 <br /> rrr_ <br /> Waste Tire Survey & Inspection Report Inspection Report umber <br /> stat rcaidoaw Survey Form - Page 1 12 1 Q 7 9 1 5 9 <br /> CM/Ma 18ast(Naw nag <br /> Califsmla 4104) <br /> Integrated Waste Management Board <br /> Part A•Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r �D 5 Z 3 Q - O / Inspection Type (Fill one) ---- ---- <br /> Site Suffix: Il /_IL_ U 0 Routine 0 Re-inspection 0 Referral 00 <br /> bservation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> S�r•t 30R u�►� �v^/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I anew-�- <br /> 2/2o0 - <br /> Street <br /> Inspection DateCA <br /> ,7 a <br /> sit — tate ZIP Code i Time In Time Out <br /> Business Rep - Title O AM O AM <br /> --"-E -1Z--JL- NJ m•m O PM ELI <br /> .m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I I 1 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> �Active O Passenger 0 Generator O Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> _ _ <br /> L'_ -I—_--L--I _ 11�--' Q Inactive �Truck <br /> Longitude - (- - -I- I _ I I— O 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements - Data m / m / m � <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0'�0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments Al <br /> Bir�.�p_�c7zo,✓ of 7�.,1_ +c._!.-i�<�/�-s �r�-ice,s�°f'� w� <br /> Rem iii. all c%ys-rz !'!A," A/t� �ispssed o< <br /> r�Z N P� �/t�, �fl E �op_e.s_e4JO <br /> Inspection Form Included:0 p <br /> Q <br /> Comments Included: ---gn— ---- <br /> Business Rep's aumber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect:VX <br /> (� qj E X A M P L E) ) z 362081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />