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©sc�sivq©zy� <br /> rrr <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> r; CmimsCalgomia Survey Form- Page 1 I1 - 1.088379 <br /> GIraty 101sNew nage y <br /> Ca111om1a Integ2ted Waste Management Board <br /> Part A-Survey" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _I / Inspection Type (Fill one) <br /> Site Suffix: J y 3 O 4 31 J I �` (IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> Lo�'y TO <br /> � I If Referral,choose referral type(Fill one) <br /> Identifier: O <br /> Ident0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - — — - Inspected By Inspector <br /> Physical Address L, <br /> 4101 S. des no A ve, ^� <br /> Street C4 q5,-20& Inspection Date <br /> J <br /> City - State JP Cade Time In __ _ Time Out <br /> Business Rep Title T� O AM I�— Q AM <br /> Ayt�oI <br /> C): I �� g 10 <br /> - tus Tire T Business PM <br /> Operational Sta PM <br /> - _ �l.'' Type Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (fill all that appy) (Fill all that apply) (Fill all that apply) <br /> CJ 0 Active ®Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0!Indoor <br /> --- _ - O 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appy) <br /> 0 New Tire Dealer 0 Auto Repair ®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 I <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 /> 0 0. PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 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 Date m / 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 EXT) <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 0 Referred I 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 Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> CommentsuC 1,•&n_ • `S ISO >�S TU I��GiJZ <br /> ' �r1�L r <br /> "a,�is wash_ a ct.SeA 4 _mss )GI- ✓4d'edd � Ce. � <br /> �I_0 �d'lts <br /> Inspection Form Included:0 <br /> Comments Included:0, <br /> Business Rep's Signature Phone Number Inspector's gnature -Phone Number <br /> 081 <br /> ■ INSTRUCTIONS ON BACK Correct:* Incorrect:X& E X A IM P L 1 2 3 621 ■ <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br />