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08206040142 <br /> =«= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> eee_ <br /> Cute-te181(NGw Survey Form - Page 1 - 11 - 10 7 9 2 7 3 <br /> c1wMa tet thew oaoal <br /> Callfomta Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details• <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: n 8 9 D� / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: N � +r'�/ (�lst(NT-L� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name N <br /> Inspected By Inspector <br /> Physical Address 3 9 - (,)TtLT I!!! <br /> Street <br /> C <br /> I V�C/'x-�57� C�/f 9525 I Inspection Date L✓� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 11-1 <br /> m O PM O PM <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) . <br /> 0 Active ®Passenger •Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude I l J,I —� Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> LongitudeI `I 1 I• I I_- Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply). 'll 113 J _ JJJ <br /> Q 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 •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ __ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 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 EXE <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/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 <br /> w/fc r�/ 1LE.tYe" _may/lJ��tP aVt�B.- 1�.C--�I��LaI)';��✓0..Li <br /> —,Jm �¢.AQ. fs'•� _/?t.�.=, <br /> / ot�•lrao—����4' dt/.c,oa'�e �'.e Lo 1/s e.1�3 A)oIV <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK "C. Cll <br /> IncorreRopy,. <br /> 62081 <br /> EXAMPLE 1 ;23White Yellowrattx Pink Copy:LEA ® M <br /> FILE COPY <br />