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08038040309 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> r1G State of California Survey Form .- Page 1 - 1 2 - 1 0 7 9 4 0 1 <br /> CIwMa 7B7(N-0414)naog. <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID• III '- uQ / Inspection Type (Fill one) <br /> Site Suffix: 1/ �9 ( I Fl. Zl ' ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: `T74�-ttVt CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility.Name Inspected By Inspector <br /> I L� S�nt s �ucfw>w�-1 _ F1T6 <br /> Physical ress <br /> Street b 1 r O <br /> Inspection Date <br /> L <br /> itL State ZIP Code Time In Time Out <br /> Business Rep QQ Titl/e0 AM 0 AM <br /> � m' O PM L_11:EEI WPM <br /> ' 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 /> ' r ®Active ®Passenger ®Generator (S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude j I Q Hauler Q Indoor <br /> —1 <br /> - � _ <br /> _JI—JI Q Inactive Truck <br /> Longitude 1-1.]— <br /> • — 0 Planned <br /> Q End-Use Q Container <br /> ® <br /> OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel - <br /> p Used Tire Dealer Q Auto Body Q Car Dealer p Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other L � <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility FO,R,-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Nottce 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate m / [1] / m <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 EXTJ <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 A <br /> tAd-�'yt'LA`LtnSjJC-..e�ar�►v s7e "moi S [W.a��.— _�4c%�r2if4-j�`LQf�✓-�Y. <br /> -►zs—rr�'rc.l_,< —yr�e��'7f�'JD_ �ia—a �- —la� is� ✓!�a/—fo- 2k4 —firs c <br /> d�=�iP�-►�•—��i?m�i1' Sd7r/. 12rinfr-� ���GLree�r�ui per3'-�rrr <br /> Inspection Form Included:Q <br /> Comments Included:Q - - �C - - <br /> Business s S_Ignature Phone umber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: [E[XA M P L E 1 2 3 <br /> ■ White Copy:CIWMB YelloW Copy Operator Pink Copy:LEA <br />