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08227030001 <br /> rra_ <br /> Waste Tire Survey & Inspection.Report Inspection Report Number <br /> state of Calff—la <br /> Calnomia Integral d Waste Management Board Survey Form - Page 1 Il 1088109 <br /> Part A-S <br /> ur <br /> eBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / (",y� Inspection Type (Fill one) <br /> Site Suffix: 2 3 ! 0 0 Routine 0 Re-inspection . 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: J J //— 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U <br /> f , C ���� � Inspected By Inspector <br /> INI a /��— /yc�e - O <br /> I r <br /> Physical Addss ( ( A&Df <br /> L_32_��. q9 I <br /> Street <br /> Inspection Data <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title I ,; Q AM I I f I O AM <br /> ;QPM , 0 P <br /> - Operational Status�( , <br /> Type Business Role Storage Type <br /> /'� (Fill one only)� llthatapply) (Fill all that apply) (Fill;all that apply) <br /> Tire Count(Whole/PTE) � 0 Active Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude r 0 Hauler Q Indoor <br /> _T O 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 6 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 0 Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility BENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires. 0 Notice Of Violation Q Extension <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 /> MI III / m <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 NOV or FXn <br /> 0 0 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 Q Referred!CIWMB Enforcement <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 C-ompliance - No Violations <br /> 0 1 0 Other: § <br /> comments <br /> -- - •J� %�/��o� e ,,-ayf—' _ c- %'nom vt,��: �10-Ta <br /> —%� /�-�'�--J��—�-�`-�c,�—f-7�'� YL�/ccic�(i_/�tP.l.J�eG_er_✓_���.te_s— <br /> Inspection Form Included:0 P209 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor eet: I�C-pOper.Wr <br /> 62081 <br /> Exa � PLE 1 :23 <br /> ■ White Cop CIW M Pink Copy.LEA ® ■ <br />