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08227040101 <br /> CWaste Tire Survey Unspection Report Insbectlon Report Number ■ <br /> S-1—c-1-1. Surve Form - Pa e 1 1 $ - 101088crwMB 181)New 04104) Yctegrated Waste Managamant Board . <br /> Part A-Surve BLUE.OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- / �y / _ O / Inspection Type (Fill one) <br /> Site suffix: a `r 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .. 1,4N J 0 Q CHP Q CIWMB Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name - -- <br /> Inspected By Inspector <br /> yCDx t--o�7„ccsTi rc .Se ✓�c e 13 a�r _ Ft <br /> Mo / <br /> Physical Address c <br /> 1 670 T - <br /> Street <br /> — CC '} Inspection Date <br /> City /�A � CA Stale! <br /> J9' Time In Time Out <br /> Business Repo Title O AM Q AM <br /> _LLI 8/P.r �✓rte` ��Nt�t m•m PM EEI <br /> 'm PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) [:T <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ��e �L� 15� <br /> J � �Active 0 Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use *Container <br /> 1-T-E- <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer Q 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 <br /> Part.6-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STgTUS _ <br /> V =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 LU <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q .14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requhed(or NOV or FXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> --------------- <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 /> 010 1 Other: § <br /> Comments <br /> WO--+�- <br /> �6ft�1' �(,,Y.• <br /> fii/ !ii a raJ�ai1 _ X71 dzJ,ob,,.n'�iaJ�s—t/i_�.,J•t�._Na ✓r'a�w7 %tJ' S 0/2 <br /> Inspection Form Included:Q P3s_o�k•a ` ' / I ^�� 9(�$ g(��3 <br /> Comments Included:Q — ����•••� /� <br /> siness Rep' Sig ture Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK •orreet• Incorrect: LE 62081 <br /> EXAMP123 ® ■ <br /> White py:CIW B Yellow Copy:Operator Pink Copy:LEA <br />