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0823.4040037 <br /> 111- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B California T i — 1088159 O 8 8 A r 9 <br /> CIrated 181 IN" <br /> Mange .Survey Form - Page 1 11 all 'V1 <br /> Callfomla Integrated Waste Management Board <br /> Part A.SUrve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / _ O Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address <br /> I <br /> 1055 W G1� Sr <br /> Street Inspection Date <br /> L STa G�2�try, C A 45 20�S j Time In Time Out V <br /> City —safe ZIP Code <br /> Business Rep Title Q AM Q AM <br /> 0PM QPM <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 /> f i Active O Passenger 0 Generator O Outdoor <br /> - _ -- - -- o Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Inactive 0 Truck <br /> O <br /> Longitude I O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer O Auto Repair p Trucking Fleet p Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder 0 Other I Cali5T!L.ti�77_D/1-�,n[1Aw1 J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT SI L Y <br /> y q HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/GIWMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> 1_21.1; '.x' �.�o-� G!/_7_sc�—�ilau�_av—/ � r �'s_ta.�.�•DJr� lta.l •t_.— <br /> �'Id.�t.� A 1/rO/a,�'oy,s 41- GQ,.t w.•,s �er^F�P. <br /> Inspection Form Included:Q r C 4 <br /> Comments Included: — f-7-1-U �JO 0 �� �a�b}� <br /> 01— <br /> es. nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co t: Incorrect: E XM4 A P L E. 11 2 3 62081 <br /> ■ W to Copy: I MB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />