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08262040548 <br /> u�= Waste Tire Survey & Inspection Report inspection Report Number <br /> nr <br /> rr crwM"a'"'reo Su rve Form Page 1 Il - 1088208 <br /> t:grided ,tom•eon, Y 9 <br /> GalHomla InNyMaA Waafa Ma�uaamam Boats <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ► �{ 5 9 5 G Inspection Type (Fill one) <br /> ffi <br /> Site Sux: 2 3 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I Sayi Tocaquiq COUn+3 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> —7 <br /> i_f�7reV1�►er's G�att-ol =ce Cr4ar+n� Krishan Lu—Q.s-1 <br /> Physical Addiess 3 9 - FITO <br /> i-1.351 D_u P o n1- Gt. I <br /> Street <br /> Inspection Date 0 8 3 Q 8 <br /> I—M.unt+tcq GA 95336) <br /> Crty State %IP Coda Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM I I � O PM <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fiil'all thafappy) (Fill all that apply) (Fitaitthat appy) <br /> r r 0 Active Q Passenger le Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ,; Q Hauler Q Indoor <br /> - '- - - Q Inactive Truck <br /> Longitude. - i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that ePPM _ - <br /> _ QTe Derived FuelNew Tire Dealer QAuto Repair �Sruckin Fleet QGovernment QRetreader Dismantler <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 0 Other Lp1S �b �orl C. n±e t' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A A DM S Q I EM- <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehide <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Required f r NOV or EXT) <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 Referred/C-IW MB 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 balers or Waste Tire Generators In Compliance - No Violations <br /> Q 10 1 Other: § <br /> Comments 04��� ��5��_Oh�� �+�OelGt7►��IS—��+iLG � t_►�LO�QJd�6-145��O_I_D�% <br /> �as,�G�o_.,,_us3s lees Sc16w4�'TC_r fir_e�et�I�CR � ulas�iYJe,�r�+ _ov_q�. <br /> F�,s.�li�-�1o4s� �1e��o�CgL1�ut�4z��Koks�as �d'1- hoed +�re5�ec�oved <br /> sin_cR.�as� ear.EnT—c��nttess vitt.�e.d . ►�lo i alq 'i oris or c�eas a co�u n. <br /> Inspection Form Included:Q !� (Zan) <br /> Comments <br /> Business Rep's-Signature ' Phone Number p or's Signatu Phone Number <br /> 62081 <br /> " -INSTRUCTIONS ON-BACK Caorr c : Inc rrect: [flX A M P L.E <br /> ■ While py CIW Yellow Copy.Operator Pink Copy LEP; ® ■ <br />