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Waste Tire Survey & Inspection Report 08123041e73 <br /> cee_ <br /> Inspection Report Number ■ <br /> u SfatmB 81(New Survey Form - Page 1 1 5 1 0 7 2 8 51 <br /> CIWMB 181(New nage <br /> Cali/omla Integrated Waste Management Beard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- 1 y/ I Jig q _ O / Inspection Type(Fill one) <br /> Site Suffix: L/ l 7 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Jjy4qw &OAA 0 CHP 0 CIWMB 0 Complaint 0 Educationat Visit 0 Other <br /> Business or Facility Name (j Inspected By Inspector ' <br /> L— s� �LANS�D2T�r CA) <br /> Physical Address <br /> I 2S& Ll / '9tvd. <br /> Street �^y Inspection Date <br /> Time In Time Out <br /> City State ZIP Code <br /> Business Rep [ TitleO A:M M Q AM <br /> ✓/it(ae[ �r�Jctl O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> i I j (Fill one only) (Fill all that apply) (Fill all that apply). (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> I j 0 Active O Passenger 0 Generator 0 Outdoor <br /> r i O O Closed O Altered <br /> GPS Latitude �_I I L I f'I� j 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude % O Planned 0 OTR 0 End-Use O Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •Trucking Fleet O.Government 0 Relreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture O Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — --- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ion <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of ViolatQ Extension <br /> i <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 <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 FXTJ <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> j <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 .O 14 CCR§18462-Manifest System Requirements.for Tire Dealers or Waste Tire Generators ®In Compliance - No Yiolatians <br /> O 1.0 1 Other: § <br /> Comments le <br /> QVn.tJ£_� f. .l <br /> –/=uJ�•t—T_2�s �a Gc��/soh G��_`i�_fa.e._R��j2er�1__Q�_�s�va�—�d <br /> f <br /> Inspection Form Included:0 z0 9 <br /> Comments Included:O -B — — <br /> less Rep'_ natur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK rrec Incorrect: E X R hh P L E 1 Z 3 62081 <br /> ■ White Co y CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />