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VOL O L V V V L'a <br /> Waste Tire Survey & Inspection Report Inspection Report Number. ■ <br /> Yi➢ State B California Survey Form Page 1 I 1 1088241. <br /> CMr tad Waste <br /> nage Y <br /> California Integrated Waato Management Board <br /> Part A-Survey" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 3 `1 19 1 7 1/ S FoTtl .Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQn 70 Ol9t.t1 n C.OUn+j _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �l�t2i-ad RQ�alls Nar}hweS�,_2tx_�5'Z.y 3 9 - 10 1 1 <br /> Physical Address h(1J I I CiR t uQ Q] { <br /> L2081 E_Cha,'�'ar W_qy I <br /> Street 9G c Inspection Date O a Z 5 <br /> , e.L-br1 C'A State Z�Oo e� Time In Time Out <br /> (Business Rep Title j�� F_i—i Q AM { Q AM <br /> QPM F � �' QPM <br /> _Ro Ta for Ser.vice__-. . r. , L— -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only), (Fill all that apply) (Fill all that apply) .(Fill all.that apply) <br /> � Qf <br /> i Si Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck N/A <br /> Longitude - 0 Planned I♦OTR 0 End Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 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 L�9U)_nrn� Rah l� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 FX7) <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 CIW MB 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 0 Other: § <br /> i <br /> Comments <br /> 4-_o_t�'t�n_�s—irls4a.ci'►o!n_��rr+ec,��is � � -t4uL --_-Lo_I.�_►ncf vis t <br /> t�cs}td-.—N�i-i�ces cut ct�4\�S�-o_r�._cl�on_sL�`'Fac.�1 i-l'�_� q 1 ow Nplt�tne, <br /> �e7ner�t}4r o wash -Ei]�.s_F �i �s��annon��ea mire -Vbr <br /> _Wq5—c—i ir��c�.m_v_ al�co►n cc�nises_. GTI.. rnant est,W%_V_4_b_een <br /> Inspection Form Included:0 - 204 <br /> Comments Included: -- �-��� i7-8- <br /> Busine p's Signature Phone Nu berI pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK G•orreC • Incorrect: 62081 <br /> EXAMPLE' 1 ;23 <br /> ■ White C py.CIW Yellow Copy:Operator Pink Copy.LEA - ® ■ <br />