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08285040020 <br /> Waste Tire Survey & Inspection Report __InspectionReport-Numberstate _ <br /> as CFWM 1B1(Nmla Survey Form - Page 1 I. 1_. - 1088223 <br /> r CMIMB 18a(New nage y <br /> Califomto into <br /> Waste Management Board �] <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - — —j— --� Inspection Type (Fill one) <br /> Site Suffix: 3 33 <br /> Routine 0 Re-inspection Referral <br /> 0Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I cSAnl V �A�.vta� CA77o� _� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (� — Inspected By Inspector <br /> Physical Address - <br /> ���5 N, — <br /> Strasi ----• I- , , <br /> Inspection Data D <br /> --%�►�-y --Gy9 9530_x_ — - <br /> �, ,�,,;;�d� Time In Time Out <br /> Business Rep Title - - 0 AM —" - — - '. 0 AM <br /> (� e 0 PM 0 PM <br /> I 0 f tAN T GrL• Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> a 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor I <br /> O 0 Inactive 0 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A 1 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 Data m / 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/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 0 Other: §, ------- -- --- - --- <br /> Comments <br /> ,� � /--�ONt inf.S�-�'7—lt�Y+_r!H_.31I—GLpK-C-• �!�C' IJ <br /> /-[•t/.c.0 Aci.ct'�u'� WG�'p-� �L CrOy OHO—��uy�r�r.s_7�� 77'CC.�IA.c{SGt'_ <br /> 112 <br /> Inspection Form Included:0 <br /> Comments Included:0 X 'YfoB L� 3 <br /> B Ines Rep's tura Phone Number Inspectoes.Signature Phone Number <br /> INSTRUCTIONS ON ACK C rect: ncorrect: (� 9 ETx FAW P L E 1 2 3 62081 <br /> ■ White Cop.CIW Yellow Copy.Operator Pink Copy:LEA ® . <br />