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08248040020 <br /> _1°. Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> °° Ste"F C."tm`a I 1 _ 1088178 <br /> califomla int grated r 'WaseeManag ment Board Survey Form -.Page 1 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 2 y 5 © - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Tp�a"^";N �UN o CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � Inspected By Inspector <br /> I Hel.j Z <br /> Physical Address <br /> I <br /> Street <br /> Inspection Date O SI O �� i`✓ <br /> L <br /> Ctt9 State ZT'Coce Time In Time Out <br /> Business Rep Title ��:7-10 AM F—T----:I__T7 O AM <br /> I <br /> --= '—�---j O PM L; I u--1---� O PM <br /> --" --- J Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) '(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> le Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> - _- 'D 0 Inactive 0 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 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�/1Aelrx�ric <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility _ENFORCEMENT STgTUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Oiolation <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice f V0 Extension <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 Date m / ELI <br /> / 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 Referred/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 0 Other. § <br /> Comments L1J <br /> .JOr9,0 <br /> %�..own c.(., "w/ - FJa�o _ Q1r� ,�,'r � <br /> —✓f¢ttJ�-8/ NO ---V Id��r�.rs�-3—A_/' ��+'��y+_._S—/VOTE-eY• - — <br /> Inspection Form Included:0 204 <br /> �3a s7y� _� Q 46gg6 <br /> Comments Included:0 <br /> Bu ess Rep's Signature Phone Number Inspectors Signature one Number <br /> INSTRUCTIONS ON BACK Incorrect: E M P I L 1 2 3 62081 <br /> C• ec <br /> ■ White Co :CIW, Yellow Copy:Operator Pink Copy:LEA ■ <br />