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09049050027 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> • '°` cSWa 1wMtOa1Ro4. SurveyForm - Page 1 I1 - 1088355 ■ <br /> Catlfomla Integrated Waste Management Board "..' <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- IF IQ IoI&I Q r Inspection Type (Fill one) <br /> Site Suffix: ' 1 IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: __TO0'Qy h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> � qc i�J@nomo 13 - Ft o I ��,�ewu ! <br /> Physical Address./ <br /> Str <br /> I T GL Gt �� J� I Inspection Date � O / 111a 4 O 9 <br /> / c � 1 I U L <br /> City (, State ZIP Code Time In Time Out <br /> BwU�S Rgpals �s Title 7,1 V. <br /> ;�J ®AM 0 A <br /> l y p D R O O PM •[1�� <br /> O PM <br /> e <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) ! rn <br /> r "`I. ®Active ®Passenger ®Generator Q Outdoor <br /> Latitude i ' !O Q Closed Q Altered <br /> GPS Is Hauler Q Indoor. <br /> II' <br /> -=-1 -�-_— — — Q Inactive Q Truck <br /> Longitude — ; E• i i o Q Planned ®OTR Q End-Use jo Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 ENFORC IVIENT STATU_5 <br /> V M HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0. 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 <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 (Required for NOV or EXTJ <br /> Q Q 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 I C-IWMB 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 1 Other: § <br /> Comments — R he d •oh -f kZS dam. CH Sr A•IFon so -ambPast <br /> Tw, 4rav' 'y_ " o �s . Norrn &JUS i Syt. is&-sw fi <br /> as a rx &cP_tKi � vy i fA 6yi roti rn enter 1 Pro(tecJT o->t. 1 n s,oec o n <br /> �C( I-e-d aheo'd d --th axce_S� over <br /> Inspection Form Included:Q <br /> Comments Included:® ` ' "c &§z- <br /> Business <br /> "'""°��G 6 ���—�O� / yo ��� <br /> Business Rep's Signature Phone Number Inspectol Signature Phone Number <br /> 62081. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: tr X aTM P E .. 1 i 2 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LFA . <br />