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08255040015 <br /> Waste Tire Survey & Inspection Report Inspection Report Number__, <br /> State or CaI(New T <br /> CIWMata„taeMaage) Survey Form - Page 1 1 _ 1088217 <br /> CalRomia Integrated Waste Management Board - - -- - — <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• y ^ i ,Er i 9 n © I I I Inspection Type (Fill one) <br /> Site Suffix: i { i <br /> — I_I •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: SA,_.TOA. ,l—�' vN, O CHP O CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V a <br /> Inspected By Inspector <br /> Physica Address <br /> 3260 W <br /> s.,�ef aa <br /> Inspection Date ' O '2—;1 C..) � Q <br /> I <br /> Tin Ti _ <br /> oy^ ---- <br /> '- me I_ __ me Out <br /> t <br /> Business Rep Title _0 AM 0 AM <br /> 11 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all.that apply) <br /> - ° J 0 Active 0 Passenger 10 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude — O Planned •OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair 0 Trucking Fleet O Government 0 Relreader 0 Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V—A ,,HAULING AND MANIFEST REQUIREMENTS <br /> O O 0 Notice Of Violation 0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m/ m/ m <br /> (D O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXn <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (ReqI <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 0 Referred/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 ®In Compliance - No Violations <br /> Q Q 1 Other: §. <br /> Comments <br /> /LA- <br /> to <br /> LA-✓V. <br /> r-s ,¢.�. {�.a Gt .. y+�1a,.,,' _ ab sa,/ t9_ /l)Q—(/�e�� o _s <br /> Inspection Form Included:Ot� <br /> -/ 4” 56 3 <br /> Comments Included: — — <br /> Business Rep's Signatur Phone Number Inspectors Signature Phone Number <br /> �( E <br /> INSTRUCTIONS ON BACK C rrect. Incorrect:� �J& XAMPLE 62081 <br /> 1 2 3 <br /> ■ White Co y Cl- Yellow Copy Operator Pink Copy LEA ® ■ <br />