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08038040316 <br /> rr•- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> cWMOa1fN 1 2 . 1073392 <br /> CNYMB 1611New OuO�) Survey Form - Page 1 <br /> Ca Ofomie rntsgr ted Waste Management a°ard <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O C �y _ ODI <br /> Inspection Type (Fill one) <br /> SiteSuffix: 1 ��l11,]) ®Routine Q Re-inspection Q Referral Q Observation <br /> Localf �� , If Referral,choose referral type(Fill one) <br /> Identifier: f L�V 0� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i rOc PO n,-�a e G M C <br /> a�ag RDb��n L�� I <br /> Street <br /> I Trac, CA-- '757309I Inspection Date <br /> _ <br /> City State ZIP Code Time In Time Out <br /> Business Re/p// tf Q AM 0 AM <br /> Vl `;ri/l m' m O PM LLJ: 0 PM <br /> - -" - Operational Status Tire Type Business Role Storag <br /> Tire Count(Whole/PTE) e Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 't I � j � I , <br /> ®Active I ®Passenger ®Generator Q Outdoor <br /> GPS Latitude -�— I•( ` 0 Q Closed 1 Q Altered Q O /V/A <br /> J _J Hauler Indoor <br /> r r O Q inactive Q Truck <br /> Longitude - I J Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 L <br /> Q 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 ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice tx Violation Q E-xtension <br /> Q Q 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 Vehicle <br /> Q Q 14 CCR§18459 -Responsile Entities <br /> 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 (Required for NOV or HXfJ <br /> Q 014 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/1311111 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 Co pliance - No Violations <br /> Q Q Other: § <br /> Comments lesr,d,`,_ _ _ -Al's „f de ALL-,5• � C <br /> C_VC - - Q <br /> Da(.&ornca WagPlire �(�yv fe - e cii shoo,,-, CFL wuak <br /> r✓yt 5 Y'e✓ielA i LWuk, }� yrala Z�nS crf <br /> _ i <br /> Inspection Form Included:Q p2� <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector' Signature Phone Number <br /> -- - -- ---- <br /> INSTRUCTIONS ON BACK Correct: Inco reef: E X A M P E 2 3 62081 1 <br /> . White Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />