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08248040021 <br /> '" Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> GGBS $tale Of Calitornii <br /> sii C$1 -B1c 1-1_1 04) Survey Form - Page 1 11 1088189 <br /> calltomia Integrated Wasta Management Boats <br /> Part A-Surve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Q I Inspection Type (Fill one) <br /> Site Suffix: tijO <br /> I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: N - � J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LMpcdf iya W eoG1'�ro�us ' <br /> Physical Address n � � - I � 1. o 1 1 ?All f ,1J I <br /> L_2 3 y 2 -t?>A_NTA �� l <br /> Streif <br /> f!;3-?� inspection Date YVS i� <br /> Time In <br /> State Trp Co Time Out <br /> C/t;r e <br /> Business Rep /Q Title =I:F O AM L r-I 1I I Q AM <br /> _f !"l"Or e2 L--'�J 0 PM I!�.I 0 PM <br /> O - <br /> - - <br /> Operational Status Tire Type Business Role Storage Type <br /> pr! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> *Active Q Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> --.0 0Inactive 0Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Railroader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O'Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other L— Al zl_e 4�S—J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility RENFORCEMENT STATUS <br /> ------ ----- <br /> V A .HAULING AND MANIFEST REQUIREMENTS Q Notice Of utotal'on 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 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 (R quired for NOV or EXT) <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 of !C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q_ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Viotat(ons <br /> 1010 1 Other:/§� '' n <br /> Comments IC�T ,1rt/L'_C"f a G�YYy-, CYt �Z✓10 d —/ ��� J w/�-o xw�syr: <br /> —� — _ ,� /flu=W/��✓�'1 ��/�hc� <br /> 6 u-r n S A)z I_%j , <br /> Inspection Form Included:0�'t <br /> 20QQComments Included: .Q--��'Phone Number' Inspector's Signature Phone Number <br /> . INSTRUCTIONS ON BACK e 01.-I ri X a Ah P L 1 2 3 62081 <br /> White opy CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />