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--- -�- ---- 08080040024 <br /> tor. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> u <br /> State o11811ornla Survey Form Page 1 4 - 1 0 7 9 4 9 9 <br /> CIWMB 187 stew na e) <br /> Calitomla Integrated Waste Management Boartl - <br /> Part A.S=e BLUE OR BLACK INK PEN <br /> Business Profile - - Inspection Details- <br /> TPID- o _ Inspection Type (Fill one) <br /> Site Suffix: p 0, 0 0 Routine O Re-inspection O Referral O Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: \ A�?��„r.. Cou^ t'� O CHP O CIWMB O Complaint O Educational Visit O Other <br /> BusinessSor Facility Name Inspected By Inspector <br /> Physical Address <br /> i[iE] - 0 I f�►� K4 ���f't�` I <br /> I 3 3_s O N_u_�,c,t,t,rte( I <br /> Street Inspection Date <br /> v� SZI.0 9 <br /> City /��-v State P Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> m®PM [I] :m ®PM <br /> -7�tti µOPG _.tet - -- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (/ ®Active (a Passenger . ®Generator O Outdoor <br /> GPS Latitude L[ I I i-l— f O O Closed O Altered O-JI-JI J <br /> Hauler O Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer i9 Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber. <br /> O Service Station O Hauler O Agriculture O Shredder O Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m/ m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXr) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-,Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O 1 O Other: § <br /> Comments 1r14rrkrl,m. �kt.tf 4(Qtte�_•—� ( rJ— rc <br /> �n�<H gf��ts41s.1t.Ke( �i�u?zr•%.-G.r yC cG r�2o1�.•2- f'!•�%c_✓..ad_ 421 <br /> is /rylt _ ter Ann 2 - //KS 2n+0Ycd 7-19o/�l <br /> Inspection Form Included:O /x <br /> Comments Included:O—, - — - �er _,' <br /> Business Re 's Signat a Phone NumbInspectors Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK rrect:0 Incorrect: I E�X JAMjP L I E 1 62081 2 3 ® ■ <br /> White Copy:CIW MB Yellow Copy:Operator Pink Copy:LEA <br />