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09210040005 <br /> ;_ Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B California _ T 1 7 7 <br /> - 04) <br /> Califomia integrated Waste eManagement Board Survey Form Page 1 + + 1 1 0 8 4 1 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I i Inspection Type (Fill one) <br /> Site Suffix: r� <br /> L 1 s� L i I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: , J C0. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Inspected B <br /> Business or Facility Name Ins Inspector <br /> �� P y <br /> Physi cal Address �Rq O. 1 Loa <br /> �t17C?ti <br /> S�o-t_fs_��e i `/�.v� �l/�L�SL _ <br /> Street I <br /> L— nC / + Inspection Date <br /> City J �/1 Spate ZIP Coae Time In [jL <br /> Time OutBusinessRep Titlel�/� � I – 0 AM I I r 0 AM <br /> _ IVl-Il ev, I® PM ��Q� / �I ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The COUnt (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that.apply) (Fill all that apply) <br /> ®Active ® Passenger ®Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> -O Olnactive ®Truck <br /> Longitude - 0 End Use 0 Container <br /> 0 Planned 0 OTR <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 I I <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT_STATUS _ <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / m / 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 E>M <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 0 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 <br /> ®In Compliance - No Violations <br /> 0 0 Other: § <br /> 11 <br /> Comments ri <br /> it S —dcLt_�. `�(Q-1.-•4 <br /> r -t%r�_�,oct,t� � cQ•ts��Sa�. CMZ ���s Iry r mS v; � --- <br /> 00 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 � J <br /> C /`� (G� <br /> Business Rep's Signature Phone mber Inspe s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: I orrect: ?v(�p X I AJIM I P I L I E f 12 3 . <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />