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08157040075 <br /> eco_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> °°` Ste°real.(°r°'a Surve Form - Page 1 1 5 - 1 0 7 9 2 4 4 1 <br /> cIWM13191 Inew gaaal Y (y <br /> Callfomla Integrated Waste Management Board ".J' — <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � / / I� � © ` 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:. 1 S/,da.�.�•� I�IVTs2 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "' Inspected By Inspector <br /> j1jorif� F/TY T�/lc L iHt� q <br /> Physical Add(ess I ( O <br /> 3�os S. aL ao�o <br /> Street <br /> — Inspection Date <br /> 9520 _1 S 2 tl g <br /> City State Zip Code Time In Time Out <br /> Business Rep TitleO AM O PM <br /> S <br /> — � O <br /> Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> r 1 �Active �Passenger 0 Generator Q Outdoor <br /> I T Q Closed Q Altered <br /> GPS Latitude i i I I i Q Hauler *Indoor <br /> __I'�_- _ _^.I Q Inactive IS Truck <br /> Longitude I I I I 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 /> 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 , I <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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 for NOV or FXn <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 Win Compliance - No Violations <br /> Q Q Other: §t f� _ <br /> Comments /J���iV�_/ySQQ� /eyJ Q�!st13 G QI�OL✓11N9 &1ti Alorg./ f <br /> w�GClirsA).7-1-J. <br /> Zo9 <br /> Inspection Form Included:Q '2' <br /> ,� Q <br /> Comments Included:Q r=�`'—�0 <br /> Busi ess Rep's SI nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct:�Incorrect:VQ(% � EXAMPLE 1 :2 3 <br /> ■ While Cop. Yellow Copy.Operator Pink Copy:LFA ® ■ <br />