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08129040870 <br /> Waste Tire Survey & Inspection Report . Inspection.Report Number <br /> r7 cratMa 8'(New <br /> SUrve Form - Page 1 1 9 - 1 0 7 2 8 5 5 <br /> CIWMB'wastew nage y ('� <br /> California Integrated Wasta Management Board "�' <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> I <br /> Business Profile Inspection Details <br /> i TPID- T�-T <br /> � /'3mInspection Type (Fill one)Site Suffix: I D 13 `� I - U •Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) ' <br /> Identifier: ��q�/�p�C •� inJ two d�1 `�^ Q CHP Q CIWMB - Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - V Inspected By Inspector <br /> 1 a �ti �9�k,Pm Le�.s•N� , 3 4 1 i�,►rt H,aran&� i <br /> Physical Address _ <br /> S`055 S St car r I <br /> Bret t Inspection Date <br /> 95206 , <br /> City State Zip Code Time In Time Out <br /> Bu-siin'e-ss Rep Title OA 0 AM <br /> i ✓C r'YI2S_ ..A�(ae. ---Ji_-/ pry�NIA/J m• P <br /> m O M m m O PM <br /> Operational Status Tire Type Business Role 'Storage Type <br /> j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> I QClosed. Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -TI-T <br /> _cc 1I—J.__. --JJO Q Inactive �Truck <br /> Longitude - 17 _j; I I Q Planned' Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) I __ 111 JJJJ <br /> Q New Tire Dealer Q Auto Repair 0 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 LV Tau�1c t�e•�/� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility BENFORCEMENT STATUS_ <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> I' Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 FKT) <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 /> 010 1 Other: § <br /> Comments <br /> �eccr%��i.:�►s�G��—�*+—L�s�aa�-.—/�r_,e,—,'moo/%o-w._nr� w0.s o:��?a.�.s_ratw..'/� <br /> 14A[, r. <br /> Vre,Ic,,,O. Na ✓af,_r _f5 a,e CaHeeA JS Arbr6,pl <br /> i <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busy AssRepes Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAlhile <br /> K C•o re- Incorrect: X A M P 1, ! 1 2 3 62081 <br /> . Cop .CIWM Yellow Copy:Operator Pink Copy:LEA ® ■ <br />