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08206040132 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> 11° state of California <br /> Survey Form - Page 1 1 9 - 1 0 7 9 2 7 2 <br /> Cr.Z.101(New 04104) <br /> California Integrated waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- © D / © / Inspection Type (Fill one) <br /> Site Suffix:, "� 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local G If Referral,choose referral type(Fill one) <br /> Identifier: J/�yJ J ; �AJ Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other. ' <br /> Business or Facility Name -- <br /> / Inspected By Inspector <br /> Z/( <br /> Physical Address <br /> -- <br /> Street <br /> Inspection Date <br /> -� <br /> City State ZIP Code Time In Time Out <br /> I—Busiiness R4eep— -----—�LTitlleQ AM Q AM <br /> W FTI 0PM [IT PM <br /> 4 / .. <br /> Operational Status Tire Type. Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE); ;, tl I <br /> 40Active 0 Passenger 0Generator *Outdoor <br /> Latitude I J a 7 _ ISO Closed Q Altered <br /> GP$ p Hauler Q Indoor <br /> 00 Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> _ _I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer- 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture 0 Shredder Q Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATlU_S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice of Violation t�Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ompfiance Deadline <br /> O 0 PRC§42956-RegRespi Responsible <br /> l in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O '14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required Ior NOV or F <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-'Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators jn Compliance - No Violations <br /> Q 1 Other: § <br /> Comments <br /> fb..r�___, <br /> Inspection Form Included:Q / 2a <br /> e9z <br /> Comments Included:Q 44$ q(,?. <br /> INSTRUCTIONS <br /> Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: ExannpL � iz3 62081 <br /> ■ Whit Copy M Yellow Copy.Operator Pink Copy.LFA ® ■ <br /> I J <br />