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031IS7040123 <br /> .r <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> •r <br /> State of 181[New <br /> Survey Form.- Page 1 1 4 - 1 Q 7 9 2 1 0 <br /> Cgrated 1(New nage <br /> Call}omia Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection.Type (Fill one) <br /> Site Suffix: F/T,3 12 5- 11] _ © / 111I Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: tI�� � dN -_ 0CHP Q CIWMB Q Complaint Q EducationaLVisit Q Other <br /> Business or Facility Name V inspected By Inspector <br /> Physical Address <br /> - <br /> Street <br /> ��J Inspection Date <br /> State ZIP'ode Time In Time Out v <br /> Business Rep Title 0 AM 0 AM <br /> m' O PM ED m O PM <br /> 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 i 2 <br /> r 0 Active 0 Passenger 0 Generator 0 0 Closed Q Altered Outdoor. <br /> I —?—�I) <br /> GPS Latitude L�� I,L I — I —J_J 0 Hauler Q Indoor <br /> LD Olnactive ®Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0. PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> III <br /> 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 /> 0 1 0 1 Other: § <br /> Comments <br /> —Zor.0ir c7 L• %�/ cT�.J ���i/S�a -.—/ // a?a%� c.k.s' �t o% ' <br /> _/(� �_✓/ T3 �/i ecJ�. Na / 1-77A nLS.--8R �_nt c�r2nLs /l� <br /> -201 <br /> Inspection Form Included: <br /> Comments Included:0— — — <br /> Business Rep's nature I Phone Number Inspector's Signature Tlbite Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect: I correct: (( E X Ail A4 P .L E 111213 <br /> 3 <br /> ■ White Co Yellow Copy.Operator Pink Copy.LEA ® ■ <br />