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07312040420 <br /> tea <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> ii State of California <br /> CIWMB 18aste;ana0e Survey Form - Page .1 14 - 10 7 3 5 6 8 <br /> CeOfomia Integrated Waste Management Board <br /> Part A-SI= BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Q Inspection Type (Fill one) <br /> Site Suffix: /' 3 9 2 r$ <br /> ®Routine Q Re inspection Q Referral Q Observation <br /> 71Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint. Q Educational Visit 0.Other <br /> Business or Facility Name <br /> p Inspected By Inspector <br /> 1. vc•�oCo 4�+'lclr�ra <br /> Physical Address <br /> Street <br /> Inspection Date <br /> � n C-A <br /> City State ZIP Code I Time In Time Out <br /> Business Rep ( Title O AM <br /> MOAM <br /> 0 PM m•m ®PM <br /> ( Operational Status Tire Type: Business Role Storage Type <br /> Tire Count(Whole/PTE) I I 1 „[ (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> f �(J ®Active Q Passenger -®Generator Q Outdoor. <br /> f I D Q Closed Q Altered <br /> GPS Latitude .L Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> 1.11-1 <br /> Longitude - Q Planned ®OTR Q End-Use Q ContainerBusiness Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair e 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> O 1 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 PRC§42956-Registration/Decal in Vehicle - <br /> Q' Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date LJ <br /> / m <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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB 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 10 1 Other: § <br /> Comments <br /> �trt�'�,u'�_�/.;,+�- �y—,ayts�.a/nv�� %i rc -�✓D.'ctsyru:�.tp✓__- /)1/�—✓7b1��'urt s <br /> Inspection Form Included:Q' , l <br /> Comme �� <br /> nts Included:Q t•Y� <br /> Business R 's Sig ature Phoe ber 4n. ec�1.1BSi.natureRu'mPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACCorr t:l 'Incorrect: E X A M P 'L •E111,2131 <br /> ■ hite M Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> I <br />