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08066040043 <br /> € , Waste Tire Survey & Inspection Report Inspection Report Number <br /> alt Sta_­­_(N'.-.'.04/04) <br /> eotC (ornia Survey- Form - Page 1 1 3 - 1. 0 7 3 4 2 7 <br /> clvvMs tet txewoarosl ry <br /> call(omla Integrated Waste Management Board :J <br /> Part A-Survey. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TIMID- O ^ O ! Inspection Type (Fill one) <br /> Site Suffix: S / - f o Routine 0 Re-inspection 0 Referral 0 Observation <br /> 1 / 1Local If Referral,choose referral type(Fill one) <br /> Identifier: f Obi f�� h 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �C Inspected By Inspector <br /> des 13 �I - lToF11 <br /> Physica%1d ss <br /> I— v+ tf•0 Card"4 AV(? I lir�r w <br /> Srroer <br /> Inspection Date <br /> City Stated Time In Time Out <br /> Business Rep D111 Title AM Q AM <br /> MO <br /> O PM 'm 0 PM <br /> Operational Status .Tire Type" Business Role Storage Type <br /> Tire Count(Whole/PTE)' If 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (%. I ° _ li tj Active ®Passenger 0 Generator I ®Outdoor <br /> 1 O 0 Closed 0 Altered <br /> GPS Latitude W 0 Hauler 0 Indoor <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 /> Is New Tire Dealer ®.Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler- (�Tire Derived Fuel <br /> 0 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 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 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 M / 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 EXT) <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 I 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 /> 101 0 1 Other: § <br /> Comments r <br /> �` t—_-_I� c7i.ev� AF.s date �aci.�_��� it,Se5 LQ-�%n �✓'e rWLje <br /> `t �e X _ocaP e `]Z✓e oil fir Dr U� 2 c - <br /> fr. � <br /> E <br /> IIT rhwi Fe-s+ f rrns rwceiw �-- mDyiogtt' s noied <br /> Inspection Form Included:0. �/� <br /> Comments Included:0— - S3fo Z,33 <br /> Business Rep's Signature Phone Number lnspectqMs Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X X A A4 P I. E 1 2 3 <br /> . While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />