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08129040843 <br /> Waste Tire Survey $ Inspection.Report Inspection Report Number ■ <br /> rr Cie 818liromia Survey Form - Pa e 1 11 - 1 0 7 2 8 4 8 <br /> CIWMB 1B1(New nage y <br /> Cali}omla Iniegnted Waste Management Board J <br /> Part A-]=e BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details.. <br /> TPID- Q Inspection Type (Fill one) <br /> Site <br /> ,Suffix: I I�oT 1 (�� / S O ' ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L_. <br /> �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> I—Le S Seu�a�-T '� Cn 13 - L_� � �✓ i <br /> Physical Address <br /> Street <br /> I Locb ch gs�V o ,� Inspection Date K41 <br /> V <br /> City I State ZIP Code Time In Time Out <br /> Business Rep Title ✓ m'F <br /> O PM m'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t STj D <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude I I I,I— I Q Hauler Q Indoor <br /> LLL---_J LLL�T_ I Jo Q Inactive ®Truck <br /> Longitude - � I I- J � Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) l JJ��LL <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 ENFORCEMENTS7ATUS <br /> V A AU ING A1 1 1 Pj MANIFEST 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 I PRC§42956-Registration/Decal in Vehicle <br /> Q Q :14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <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 EXT) <br /> Q O ---- --- - - -- <br /> 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 Other(:: § <br /> Comments t l L4„-U M1-� TAS J U[' d U <br /> u% Was& a2e� w� - e sus, a e P <br /> �A act I S—W <br /> Lo a Lr - e Z _ 6( Mal sd1�� 1gar�s n <br /> Inspection ForrnIncluded:Q � 9 <br /> Comments Included:WI -sinBusing Rep's Signature Phone Number Inspector's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I E X A M P L�!Z 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA - ® ■ <br />