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- <br /> 08255040017 <br /> d <br /> WasteTire Survey & Inspection Report - _�nspect�on-ReportNumberState o1 CalNornla I <br /> 6M...(New 6/N4) SurveyForm - Page 1 I1 1088. 216 <br /> caliromla IMagreted Waste ManapemaM Board _ —_ <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I t i ,I i - Inspection Type (Fill one) <br /> Site Suffix: `/2 ' `[ V 0 <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier. CJA� TQ��,�,-fJ ( r!AU V 12[A1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `/ ` - <br /> Inspected By Inspector <br /> Physical Address 1 <br /> --- �--'---- J � /mac. _OA <br /> 2,���1._. _ <br /> _ _ 30 I_p _ V�J ,_G c_�r.►_r__ —1,f vl c__12.r�_ :- --— --. --- <br /> - -- <br /> s;,ear i <br /> Inspection Date I 2, 01 <br /> 5 edc ,,p ;_ Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM O PM <br /> 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 r / Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q 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 Q Hauler Q Agriculture Q Shredder Q Other L <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date 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 EXT) <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 •In Compliance - No Violations <br /> Other. § . — -- - -- - -- - <br /> Comments <br /> �.lS.rQC_cT'o-l �y�l <br /> j�.�S -Yq_�.:�:�1tv,l/_S_G_s---�-k-i�TC.CQ—V_l�e.S T/�.S—i-�La_c✓��s_T_er_�.� <br /> . ) A�r; c_s'rs V_iec�_`�o J;01prTonlS oL�onl�f��tQ <br /> Inspection Form Included:Q 04 <br /> Comments Included:Q <br /> Business Rep's"Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co a Incorrect: 62081 <br /> • XC� �I E 7A � ;z s <br /> ■ White Copy IWM Yellow Copy.Operator Pink Copy.LEA ® ■ <br />