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08227040114 <br /> . <br /> 'U"HIMEWaste Tire Survey & Inspection Report Inspection Report Number. ■. <br /> crit $tale of Calilornla <br /> YM Cgrated asteMnage Survey Form - Page 1 I1 - 1088107 <br /> Calltomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I ` V C Inspection Type(Fill one) <br /> Site Suffix: <br /> TPID 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J pf.q ,'� CotJN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name [t - <br /> Inspected By Inspector <br /> Physical At�ess <br /> Street <br /> Inspection Date d �' � 2 S � EoEs <br /> 95zc9 <br /> Cityd — ra �� State ZIPCode Time In Tlme Out <br /> Business Rep Title Q AM -I—� Q AM <br /> e _ <br /> _�Q PM --�--1• --- -FT ! QPM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all-that apply) <br /> M ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> .'IO 0 Inactive 0 Truck <br /> Longitude _ I 0 planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appy) <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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATiuS <br /> VA HAULINGrA_A 13 P M4 I F.E SiTil REQUIREMENTS <br /> Q Notice Of Violation Q E•xtenslon <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. CllancesDeadline <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 (Requi ed 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 C-ompliance - No Violations <br /> 0 0 Other: — <br /> CommentsAf <br /> p <br /> �-0-�� � ��c-�2, t�--r-Q Cra_/+��n_er-+ Gt...—,L���ie�- r•�,i;,t/t r1 ___ <br /> AO—�L�b�A.7 5 0 �Ca•uG��-�--v <br /> Inspection Form Included:o - �Za9 <br /> Comments Included:0 ��� 4e'$ ���� <br /> Business Rep' Sig ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjXjAjMjP1LjEj 1112131 62081 <br /> ■ 'White op�Iw Yellow Copy:Operator Pink Copy.LEA ® ■ <br />