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08206040171 <br /> Waste Tire Survey 8r, Inspection Report - .Inspection Report Number - <br /> „ CrWM/cakle..04/04) Survey Form - Page 1 1 5 - 10 7 9 2 8 5 <br /> M/MB 781(New <br /> calilomia Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• O O n / Inspection Type (Fill one) <br /> Site x: K 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5A44�A �;,j llf_�atJ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 7ZBusin ss or Facility Name ��— Inspected By Inspector <br /> -.6-6/-.Js CA_;r"_ <br /> Physical Address <br /> Street1.0 - 45u Inspection Date 0 O 6 8 <br /> �5�d.�, Comg' <br /> City State Zip Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m' O PM m'm O PM <br /> Operational Status. Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I ' I O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I 0 Active 0 Passenger 0 Generator J1 Outdoor <br /> IO 0 Closed �Altered <br /> GPS Latitude LI I, —-I I I- I I 10 Hauler 0 Indoor <br /> �-1j _ _ I_�TIII 0 Inactive 0 Truck <br /> Longitude - I�I 1• �l I IO 0 Planned OTR 0 End-Use 0 Container <br /> III I i_ I _��_ _ I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Relreader 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 0 Other � A_'%, � <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> 07HAULING AND MANIFEST REQUIREMENTS 0 Notice Ot Violation 0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 0 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required far NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/GIWMB Enforcemen/ <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 I Other: § <br /> Comments11 <br /> e-►7_x!7v_.— C _/1-tl�v+%I'. .JaO- �e 7 as / <br /> ,eVa�s_ <br /> POIG��Iq o �/�Oatwr —%�1I�O�-��rCo C/� ��TS !terCcJ��✓ NO <br /> 7_ p <br /> ✓Ty/�4Ti E�n/s 2�2_ c•e.,t 1 s <br /> Sol <br /> Inspection Form Included:0 4 <br /> Comments Included:04u.ine' <br /> q/v �f"rL one cl 3 <br /> p's Signa ure Phone Number Inspector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL E 111,2131 <br /> . White C B Yellow Copy.Operator Pink Copy LEA ® ■ <br />