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08248040019 <br /> ere_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cr.VMf181 JN nia Survey Form - Page 1 I1 = 1088176 <br /> CNVMB 181(Hew 84701) �/ <br /> callfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- LL _ O D , [12 Inspection Type (Fill one) <br /> Site Suffix: 1&Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: ��� `/OAq,4,a jj �U�/•ry�' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> PhL sical Address <br /> -Ak L A414bl J <br /> Street <br /> �� ?524!% Inspection Date �J <br /> CifYnTy State Z;.o Coda Time In Time Out <br /> Business Rep Title O AM Q AM <br /> L—�—J 0P �iL_LI —I OPM <br /> rr CA[Adw,'ck <br /> - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r •Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude �,� � � 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ice iolation Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 NotOf V0 <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 NOS or EXT) <br /> 0 O --- <br /> 14 CCR§16459.3-Retention of Comprehensive Trip Lags for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/ .11111 MEIREFforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> /if�0 I-14 •�it/T7�.t` GA—rte'— I GCOt.Tt6 �Ia vQ4 r � r7�Y�e <br /> y - N O Wj�J44-Cry LN�t_N_C T <br /> Inspection Form Included:0 <br /> Comments Included: <br /> 0 - <br /> Business Rep' nature one Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213 62081 <br /> ■ White Copy Yellow Copy:Operator Pink Copy:LEA ® ■ <br />