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_ 0$U3805002U <br /> ` != Waste Tire Survey. & Inspection Report . Inspection Report Number <br /> ere. <br /> �� State of California <br /> CIWMB 1011New 04/041 .Survey Form Page 1 I . 1073346 <br /> califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� Q n Inspection Type (Fill one) <br /> site Suffix: �I 7 9 O (� -1--- ® Q P Q Q { <br /> Routine Re-inspection Referral Observation <br /> Local If Referral;choose referral type(Fill one) <br /> Identifier: �C(h,V 0GL CBlit y Q CHP. Q CIWMB, Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> j , � 0�I I� Inspected By Inspector <br /> ►���---1115✓✓+ I///L►yi-tfLL' <br /> Physical Address _J <br /> ( 1435 -- <br /> I <br /> Street <br /> I <br /> / I Inspection Date / <br /> City (v�d`_ State ZIP Code Time In Time Out <br /> Business Rep TAdcn Title (+ 0 AM Q AM <br /> EEO PM m m O PM <br /> ——- — --- —--I - -- - —- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r I. Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ��^ I:�__�_ I Q Q <br /> Hauler Indoor <br /> O Q Inactive ®Truck <br /> 9 <br /> Lon Rude1771 r- -1 J_ IT] Q End-Use Q Container <br /> - Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair. ®Trucking Fleet (a 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 IIIIENEORGMEN1T STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 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 <br /> Q 0. 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 1 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 Q' j 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1110IWMB 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 Q Other:'§ <br /> Comments <br /> _Al <br /> M J/-LPN& rnAMC- L4 Tke' -�n2_WWZ✓I T�o <br /> w4d m K/I/ <br /> w tr al Wash ,S F Z-- ea u1Tic�s <br /> Inspection FormIncluded:Q C1 <br /> Comments Included: <br /> ® Business Rep's Signature Phone Number Inspect Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor.ect l� Incorr�ct3 X A M P L 1 '2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />