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07354040042 <br /> Waste Tire Survey & Inspection Report Inspection Report Number - ■ <br /> r� State of calgomla <br /> CtWMB161(New0ue41 Survey Form - Page 1 15 . 10 7 3 5 5 2 <br /> Califomla Integrated Waste Management Board - - -- <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- p Inspection Type (Fill one) <br /> Site Suffix: i I S / 3 / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I "jDp �w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d V Inspected By Inspector <br /> .{�J�bCal F_ j� --,--T--� <br /> Physical Address i <br /> inspection Date i I <br /> rx1-a� S <br /> C� �So. <br /> Time_In _ _ _- Time Out <br /> Business Rep Title O AM O AM <br /> - - r0PM — -' ®PM <br /> y,-Xror,i �/1►Cta�crC - --- — <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 f / Q <br /> Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container" <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 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 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 /> 0 Q 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 FXT) - <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 0 Referred f 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 O Other: § <br /> Comments <br /> r,�sp�ca�r]`:'a-n—csti/�.1-�.tc—cz(�,b.. • �^. :Tr_�-G T c�QcdycQ�n� <br /> few,+-p►•+a,�,.t�l rc.z. LtK-s -Pmt^-j'-R—Qisr�s i`'"t°1'`er tRc1nN`Ge.�ti-tCt c <br /> _�d7-/�—GTl. 1!_2cv../-u�lur+-rr�ucrt._-S�++vozl^�s Virri.�rl Gt,1o»— rf• -- ( <br /> , /SD/�>'tr o_�zS4vy{a✓�+S�k•--/-rKf�n_YJ_1hCL��--/DO�.�O CtG <br /> -- VO Vt vrl <br /> Inspection Form Included:QgZ <br /> Comments Included:Q d�ti 8-'0(v 2.3 <br /> Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:0 Incorrect: E FX FAIMPILIE1 1112131 ® ■ <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy LEA <br /> .I <br />