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08255040012 <br /> eea- <br /> Waste Tire Survey & Inspection Report Inspection Report Number _ <br /> S�`°°'California I 1 _10 8 81_9 4 <br /> CIWMB 1.1(New o<,o<, Survey Form - Page 1 _ <br /> California Integrated Waste Management Board ._ <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I I i I i ' I <br /> f TpID- i I i i I Inspection Type (Fill one) <br /> Site Suffix: i ? ! y i y !�L ; - I 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> —'— <br /> I <br /> Local F If Referral,choose referral type(Fill one) <br /> Identifier: i �j�,J ��yq�_i.�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � 7`7=� <br /> Inspected By Inspector <br /> LI %tee t c keelti(AsT><Q._ _ I i <br /> Physical Address I=B11 <br /> L/ 101 <br /> Street <br /> InspectionDate U`1J <br /> T-O-elc.�- - - —C'4- _ 9524(. I i – —I-- -- -- <br /> �ta:e %IP Co; Time InTime Out <br /> Business Rep Title 1--i -I 1 0 AM j-- - - - O AM <br /> O PM p PM <br /> _ I/i') q- lCit��JA _ �<Cl�.{wI�'C: _ -- ---•- - - - -- - -- - -- - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 2' 0 O (Fill one only) (Fill all-that apply).(Fill all that apply). (Fill all that apply) <br /> ®Active •Passenger 0 Generator 0 Outdoor <br /> 0.. 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Olndoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I_ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FH / m / m <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 (Required for NOV or EX7) <br /> 0 0 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 0 Referred/CIWMB Enforcement <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 Compliance - No Violations <br /> 0 1 0 Other. — <br /> CommentsVQ-T�,.4_ <br /> AA MS <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Business ep nature° Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKdlopycl- <br /> Incorrect:VX <br /> (� .E X A Ah P LIE[ 1 2 3 <br /> ■ WhiYellow Copy:Operator Pink Copy:LEA ® ■ <br />