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I <br /> 00252040554 <br /> err. <br /> Waste Tire Survey & Inspection Report Inspection Report Numberstate of ■ <br /> r°r CCWMB18'r°`°� Survey Form - Page 1 I1 - 1088221 <br /> CIWMB 1g1(New nage y g <br /> Califomia Integrated Waste Management Boats <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r J ,Q / I - 0 / Inspection Type (Fill one) <br /> Site Suffix: `( Q , I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S JAg_..._: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name !/ Inspected By Inspector <br /> Physical Address / ?j Fr <br /> I <br /> 5/ (, / <br /> Street <br /> Inspection Date <br /> X77=�-_� 9 �1 1 _ <br /> Cdy S?ate ZIP Coda Time In Time Out <br /> Business Rep Title I I0 AM i1 Q AM <br /> L—�--' •L---t—I O PM I O PM <br /> ot7 _b_i Vial. -- <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 10 Active 0 Passenger 49 Generator 0 Outdoor <br /> Latitude <br /> 0 Closed 0 Altered <br /> Caps 0 Hauler 0 Indoor <br /> .:-_----;p Q Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 BENFORCEMENT STATUS <br /> V A HAULING DIM A_NI F.ESMREQ IREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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§18459sponsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459. ire Program ID Number from CIWMB <br /> 0 0 14 OCR§18459.2.1`-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O <br /> -14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers0 Referred/C11 MB Enforcement <br /> 0 g 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§184621'-Manifest System Requirements for Tire Dealers or Waste Tire Generators , In Compliance - No Violations <br /> 0 0 Other: §� <br /> Comments p <br /> ni G iNSp4�e r-b" 0-17 v►c Qa�t_.—I� irs..lt I �.1 /� <br /> —r_Jc_f..�-/• ��to �``�9-�— �—__ �� _ ate.. �±Y�I-o- a.a!/ /mac.:. �J�,_s�a—.V <br /> _/f+�i•� h a..,.��,_vv��wa.., / 13��1�.a.,J_��__Na V_i��a�.f_7_a�a.�e� <br /> Inspection Form Included: <br /> Comments <br /> Business Re s S' ure Phone Number Inspector's Signature - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL <br /> ■ White Copy CI M8 Yellow Copy Operator Pink Copy LEA ® . <br />