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08227040110 <br /> " Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> eu_ <br /> State of 18 (NeCalifornia I 1 - 10 8 8111 <br /> crvra1*dW 1,Manage) Survey Form - Page 1 <br /> Callfomia Integrated Wasts Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7'y <br /> Inspection Type (Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> L Inspected By Inspector <br /> i- u�7e SAN ✓Q4 %%� ri�2%qif rrCiJ STS — I O I �/ <br /> Physical Address <br /> S/�o�� ._HwY izo i <br /> ��J Inspection Date DI <br /> L�-/'4'NTf-" C� 45336-� Time In Time Out <br /> City Sra.e ZIP Code <br /> Business Rep Titlej ! I !0 AM Q AM <br /> PM Q PM <br /> r/OY► S - `-" Operational Status .Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r t Active ®Passenger jo Generator •Outdoor <br /> i O Q Closed .Altered <br /> GPS Latitude i �_- ! _ I Q Hauler Q Indoor <br /> --- O Q Inactive 0 Truck <br /> Longitude — j I Q planned i OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet I'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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 Date m , Ell <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 FX7) <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§16461-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 /> ? uwtNE—i)vFi�4_l�C.� -a—oma+ <br /> �r 0 � i� %?a+w../ <br /> _ ��cil•w Vr'�.�.�t-m, X10 VrO_L'a�/7'�r/s O�/�G_or�hs��jo�eQ. <br /> 04 <br /> Inspection Form Included:Q G Com- ► , _� M ^`A Q6}3 <br /> Comments Included:Q attire �'T <br /> Business ep's S' a re- Phone.Number Inspectors�igitature Phone Number <br /> INSTRUCTIONS ON BACK ro ect: I - Erie IEIXIAIMIPILIEI 1112131 62081 <br /> ■ White Co y.CIW Yellow Copy.Operator Pink Copy:LEA ® ■ <br />