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08128040738 <br /> nr <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of Survey Form - Page 1 1 5 - 10 7 9 19 4 <br /> C8NM8 181(New 04104) <br /> California Integrated Waste Management Board - <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection C O 1 Z Inspection Type (Fill one) <br /> Site Suffix: U 7 7 Q T ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5A Jam} ��� QUN �7,„ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name /1 !/•� Inspected By Inspector <br /> lC2Gl�h <br /> Physical Address <br /> L-3-R34�, S: L49 I ---- --- - <br /> Street <br /> I <br /> 51-364b), C-191- [ Inspection Date <br /> City State ZIP Code Time In // Time Out V <br /> Business Rep Title O AM Q AM <br /> 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> to Active Q Passenger ®Generator Q Outdoor <br /> IOQ Closed Q Altered <br /> GPS Latitude I i I Q Hauler ®Indoor <br /> L— O Q Inactive 0 Truck <br /> Longitude – �I F],FITTI-1 1 <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair *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 p Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler.and End-Use Facility ENFORCEMENT 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 bate m / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB 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 49 In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> D '•JE 1N2r�—�—l � - ! 7 �Fufi� i.ZS'er <br /> ��t r� �c�c-� � �x��_fLZeG.L_✓. Nv!/���4fif�t.Sy2 c-eryt_GB�- S <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Re ' igna re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( �j E X a M P !L E', 11[2131 62081 <br /> . White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />