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08129040760 <br /> t„- Waste Tire Survey & Inspection Report --Inspection Report Number ■ <br /> State0l California Survey Form - Page 1 14_ - 1 0 7 9 4 4 11 <br /> clwrne est Irtew oaoai <br /> callrornia Integrated Waste Management Board t <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 14- <br /> -1 - Inspection Type (Fill one) <br /> Site Suffix: L3 1 1 v I Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ;oc�r�r.11 Crn,a� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �—C�•�co_l�ee, ��c_tom_k�L_nes II o 1 L <br /> Physical Address J 3 _ - <br /> /�� � p � thrl{,Y..u�•I <br /> (Street Sy 6 3 _D_fcc� �— I <br /> inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title - O AM Q AM <br /> *PM *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> r r ®Active Q Passenger ®Generator Q Outdoor <br /> I ( j O Q Closed Q Altered <br /> GPS Latitude — �^I -J•I_ ! I- _ t I _J Q Inactive •Truck Q Hauler Q indoor <br /> l ---- <br /> Longitude - I I I I• I I i 1O Q Planned Q OTR Q End-Use Q Container <br /> I T 1.--- <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair. 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT S1TATU_S <br /> V A HAULING AND M A M F E'SN REQUIREMENTS <br /> Q Notice Of Violation Extension <br /> Q Q <br /> 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 I 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 (Require for NOV or EX7) <br /> Q O <br /> 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 In Compliance No Violations <br /> Q Q Other: §, <br /> Comments y, Q <br /> '' 11 _dW!+�—i_1'1S.Rt�t7Y� Qom,l!1t_s_dl^�L �---�C.-(.i-F�—v iGs—Ir�k"rl_►'6 !'�J <br /> B 6 5 ;►. 11-e__Q ee.r_F_. C T L s v t�e�nr_zol >�el_►-�et�.uie_�. 4e:-1 w_{�=r—amu:-► -u•_rt s <br /> - I <br /> Inspection Form Included:Q v <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number nspector s Signa Phone Number <br /> 62081 <br /> INSTRUCTIONSON BACK Correct: Incorrect: E X A M P. E 1112131 <br /> ■ While Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br />