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08129041074 <br /> _ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r� <br /> State o181(NCalifornia Survey Form - Page 1 1 2 - 1 Q 7 2 8 2 4 <br /> clwMe tet ll,M oaoa) <br /> i CdHomla Integntad Waata Managamant Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TSite Suffix:PID- ) Inspection Type (Fill one) <br /> f — ! - O , <br /> — *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Aj 0 N ci>u,y I o CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L�oo� Df til�T l i a�ucis [Ell <br /> Physical Address <br /> Street �'!! <br /> Inspection Date <br /> �Lodf, 4/c W <br /> City Stale ZIP Gode Time In Time Out <br /> Business Rep Title JOAM0 AM <br /> QPM m'm 0 P <br /> , --- _. <br /> —Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> t i r j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger *Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> i GPS Latitude ! _�•l I _ �� Q Hauler 9 Indoor <br /> r —, O 0 Inactive Truck <br /> Longitude I I 0 Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment 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 40 Other L("t�ttlNf"AG1"i.Cr2JA/ 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Co pliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (Req lied fo NOV or E3XT) <br /> 0 O -- - _ <br /> 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 BIRKEnforcement <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 Compilance - No Iolatlons <br /> 0 0 Other: § <br /> Comments <br /> acs�7�rc,a— t �_fie�_��f�tc��t —fie i2u {;ice 7.7777aleeoP_fc�lcadr_vy <br /> i___Ssd�c�occ0 o�T ifr.l<�ia�fa.Cv�_. iyia�ll �srs—,/i eW G0.�1/v tai v/a nbnls���P �as l <br /> Inspection Form Included:0 C2o9 <br /> Comments Included:0 <br /> _at a u� 4w8 463 <br /> Busrnesg Rep's SigFTatqre Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACKt: nc• rec X A M P E 1 '2 3 62081 <br /> ■ White C y CIW Yellow Copy Operator Pink Copy:LEA ® ■ <br />