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v?340fvt40341 ■ <br /> r ice. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> a7�9 State of California <br /> a� Cgratod Waste <br /> nag. Survey Form - Page 1 1 2 - 1 0 7 3 3 4 3 <br /> Califomla Integrated Waste Management BoaW <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /` ? n Inspection Type <br /> Site Suffix: (Fill one) <br /> I I <br /> [Ell ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L�_qq_7_reya _ _ / Q CHP Q CIWMB Q Complaint Q EducationalVisit Q Other <br /> Business or Facility Name -----jllii <br /> bk •fnafe, S J Ty G Inspected By f Inspector p <br /> Physical Address—,l / 1/ !� 3_q_1 O + L j_e S l/� <br /> 3. ClkfF - <br /> Street Lo dU ��� o I 0 7 <br /> Inspection Date <br /> I <br /> ity 11-0- 4— State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> MQPM LLJ O PM <br /> I - Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) I f I I (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> v Q Active ®Passenger Q Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude —�� �I T Q Hauler Q Indoor <br /> 0 (a Inactive Q Truck <br /> Longitude �— Q Planned: Q OTR Q.End-Use. Con'tajrier <br /> - <br /> Business Type (Fill all that apply) - <br /> p New Tire Dealer p Auto Repair O Trucking Fleet Q Government Q Retreader 0 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 ®Other I 11�j I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A ;HAULING AND [TJ REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC.§42953-.Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle . <br /> Q -O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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/or NOV or FXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities. <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other. § <br /> Comments f �S"lif b)i —IV s ti( 7/1A.. -&a" t/(•2Qs '� 2• TAW-- <br /> ftX f Seer�ie� .. �� }a,rkl i.Fts of f��tti w VO Ae_ wzSt We <br /> �3ir�t6 . r 6 F F41A1 �eS- CO nt n�r� .D i�ucCfi to i? nS <br /> CSLdW;d� c�6. <br /> Inspection Form Included:Q J� <br /> Comments Included:Q -�+�--� `'4 �`r <br /> Business Rep's Signature .P.hone.Number Inspecto s.Signature. one Number <br /> - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081l= X .A JVi P 'L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />