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08234040041 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> eee_ T 1 <br /> e, State B IBI fornla I 1 1088161 <br /> CIWMB,Waste <br /> nai!e Survey Form - Page 1. <br /> Califomla Inlagratatl Waste Management 9oartl <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� / � rl – © , Inspection Type (Fill one) <br /> Site Suffix: Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:- J p� �r Cgv�/�-r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name A' <br /> Inspected By Inspector <br /> (Physical Address I ( – D I <br /> 37- <br /> Street <br /> Inspection Date <br /> I C� �r72�s I Cv/ I <br /> City Stat.. ZIP Code Time In Time Out <br /> Business Rep �J Title OA <br /> m' C1 PM 0 AM <br /> M O PM <br /> - <br /> - Operational Status Tire Type. Business Role Storage Type.• - <br /> Tire Count(Whole/PTE) <br /> '(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i (,L I I 0 Hauler Q Indoor <br /> l-1_J O Q Inactive Truck <br /> Longitude – �rI �� Q Planned •OTR Q End-Use 19 Container <br /> Business Type (Fill all that apply) --_ --- — <br /> Q New Tire Dealer . Q Auto RepairQ Trucking Fleet 0 Government p 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 <br /> I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ _ <br /> um HAULIOWN_EINANIFEST REQUIREMENTS <br /> n <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extensio <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 <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(or NO v or EX77 <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!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 1 Other: § <br /> Comments J a f <br /> �NG �•u�oet.�Sar_!QYJ�� _.�s�c��0_Ld�•'�v� /�A,O^�O_J_'�.O_:—/�v� <br /> �+-et i .^0..-I Ah ✓r'o/�_ 'di,,5 <br /> Inspection Fonn Included:Q 2a� <br /> Comments Included:Q-- - <br /> __�; �6� 468 <br /> Business Rep's Sigr lure Phone Numbe Inspectors Signature• Phone Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: E X A M P L f: 1112131 <br /> 62081 <br /> ■ Whi Copy:, WMB Yellow Copy Operator Pink Copy:LEA _ ■ <br />