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08234040039 <br /> re1- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr CraeaareaIN-W04) Survey Form - Page 1 I1 1088157 <br /> rr Cgrate 161(Naw nage <br /> Caltlomla IntagraferVVMBd Wast*Managamant Board Y g <br /> Part_A-Survey" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r! � 5 � S � / _ 10T_11 <br /> Inspection Type (Fill one) <br /> Site Suffix: I Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -- <br /> Business or Facility Name U 6R_ Inspected By Inspector <br /> I �iQ gi�jcrfr.i.y9 G�/a <br /> Physical Addrelks ! <br /> Street <br /> CA 95Z 15 Inspection Date 8 S <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> OPM OPM <br /> - Operational Status I Tire Type Business Role .Storage Type <br /> Tire Count(Whole/PTE) I r1fC (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger S Generator Q Outdoor <br /> i --'0 Q Closed Q Altered <br /> G PS Latitude ,, 1 <br /> Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> j f-- <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Notice Of Violation Q Extension <br /> 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 Data m / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or D(T) <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 •In Compliance - No Violations <br /> Q 1 Q Other § <br /> Comments <br /> 'n_,G_iNs,OP.elimn_onJw Q•- /�`� �d�e�aJ� _�.Ja� I�)orE�J: <br /> �r:P.�_wad.g��11_e�'-Sem_ 1�Ti��a•—G�/�.Q.ar ir�A is�t� .��-rL��a...i.�,e. <br /> A-) - <br /> { <br /> Inspection Form Included:Q 204 <br /> 4U896-+3 <br /> Comments.Included:0 <br /> Business Rep's_Slgnature Phone Number Inspectors Signature. Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct: ncorrect:x� NZ E X a M P L E 1 2 3 <br /> ■ White Copy:CNVM Yellow Copy Operator Pink Copy.LFA ® ■ <br />