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08227040102 <br /> Waste Tire Survey & .Inspection Report , Inspection:ReportNumber <br /> C!!! <br /> or . <br /> snu m anomia <br /> Cgmt&1 Waste <br /> Survey Form- Page 1 1, 2� - .1 0 1 0 6 9 0 <br /> Califom7a Inbgratad Waata Managemant.Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPIp f Z r� _ Inspection Type (Fill one) <br /> Site Suffix: I 0 Routine ' Q-Re-inspection Q Referral Q Observation <br /> Local c, If Referral,choose referral type(Fill one) <br /> Identifier: ✓0A�'^-"� ��'.i— Q CHP Q CIWMB Q Complaint Q Educational•Visit.Q Other <br /> Business adlity Name <br /> or F <br /> Inspected By Inspector <br /> Ph a <br /> I— e(i'ow Ttiws�,cr.,fro.� �,�L I <br /> Phys/cal Address 1 <br /> ( 1:5 15:. Ave I --- — - — <br /> Street <br /> � f �`�D� Inspection Date D � <br /> /T� <br /> City' l C-4 tate lP Time In Time Out _ <br /> Business Rep Title O AM Q AM <br /> f✓/1//.3 t_ _�• ��� i m•m O PM m'm O PM <br /> f , ! f Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> E11 I IActive Q Passenger I&Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 01 ndoor <br /> 0 Q Inactive i Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> F] <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4D 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 EORC-EMENT STATUS <br /> V HAULING AND MA (FEST REQU 1R ME TS <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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle J <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB m m <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7J <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Dealersor Waste Tire Generators . n Compliance - No Vloiatio s <br /> Q 10 ,Other: § L r <br /> Comments ���✓� I �i�—Q�'1�/Js� /nJ�� �'f CL��r �N�,�./li <br /> yr•a.,•1•�. �t/o 9_.Jo-1�.0 + <br /> Inspection Form Included:Q L 4 /t M • <br /> Comments Included:Q <br /> Business Rep's i nature Phone Number Inspector's Signature Phone Number . <br /> 62081 _ <br /> INSTRUCTIONS ON.BACKtoffrec: Ineorreet: EXAMPLE 1 23While Yellow Copy Operator Pink Copy.LEA ® S <br />