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08080040004 <br /> € ,- Waste Tire Survey & Inspection Report Inspection Report Number ' <br /> SCrwM tate a"'(Nrnla $UrVle Form - Pa e 1 1 6 - 10 7 9 1 0 5 <br /> California Integrated Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 2 N 61316-13 - O Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local. If Referral,choose referral type(Fill one) <br /> Identifier: 5 Qrt 72a9w n . Go un-t-y Q CHP. Q CIWMB• .Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L-A.., 'gob <br /> Physical Address <br /> - LKr►sfi an 1�cacc.LS I <br /> 1 2�t LS Beyer Lane <br /> Street Inspection Date 0 3 11 Q 8 <br /> R �Z�( <br /> City 71 ode <br /> Time In Time Out <br /> Slate <br /> Business Rep Title 0AM C)AM <br /> m:FU 0 PM m 0 P <br /> 1 _ Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ' I <br /> J I ' v 9 Active Q Passenger Q Generator Q Outdoor <br /> f l O Q Closed Q Altered <br /> GPS LatitudeI�,�__LI—I_ I I Q Hauler Q Indoor <br /> �J IL�L� —LJO Q Inactive Q Truck <br /> Longitude - _I=,L_I I 1 1 1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair. 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection . Q Crumb Rubber L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other �LandSGq.P2_6",%ACb.V.1 MstI ria' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O 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 m m / 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/or NOV or F>CT) <br /> O O - -- — <br /> 14 CCR§16459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers eferred!CIWMB 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 <br /> In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> gotzhtne Image_ _ orr^eA_}hi5 ds` atioy�s- <br /> �a c is!i ci �as'se_ ��es—suer `Z� ace��r_r_e � w.ece <br /> plat _nb�P uQon!4q,tz+: Ti_o-4or wa5'r� �r4 <br /> Inspection Form Included: ell <br /> Comments Incl u —/ 79S�J>__ /J�J_ _ -3178 <br /> Bus ass Rep's Signature Phone Number ector's Signatulb Phone Number <br /> 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: E X a M P L E i 1 '2 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />