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09080OA0003 <br /> Waste Tire Survey <br /> I. err <br /> & Inspection.Report Inspection Report umber ■ <br /> StateMS18llremla Survey Form - Page 1 1 7 - 1 0 7 9 1 0 6 <br /> CM/MB 1B1 stew odl04) - <br /> CalMomla Integrated Waste Management Board <br /> Part A-Surve . BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 + Inspection Type (Fill one) <br /> Site suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 70_a ptA I,n �,p(l y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name LInspected By Inspector <br /> ). T <br /> �_ rner GQ S 11,re 13 Q _ y <br /> Physical Address l L�,(IS\IQt1 L-UC.Qr�_� <br /> L_I.033 M arc4, Lane, I <br /> Street Inspection Date <br /> city State h g5Z0de I �/ J 1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> '�1��/ 0 PM 0 PM <br /> St_Mun__-r� Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE)i e i (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 16 tl]Active Q Passenger Q Generator Q Outdoor <br /> Q Inactive <br /> Q Hauler Q Indoor <br /> O Q Closed Q Altered <br /> GPS Latitude -L _��O0 Truck <br /> ongitude Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q.Trucking Fleet Q Government Q Relreader 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 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 Q Notice Of Violation Q Extension <br /> Q Q 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 m / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or D(n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> Q 1 Q 1 Other: § ,`- 1 <br /> Comments p p U�2—tgS�?2C�tO.Y_L r QCY �—fin IS_�A _�d J I O l_G1 t 011.x_.ALIS <br /> ece�le��ucrea'tc��a►��4�1Qo� r5 ;on_. Far-� -k-A_n?_L1,e <br /> r—t,aae—4 i..r_e�ciaulin�. <br /> Inspection Form Included:pi _ <br /> Comments Included:Q — a /moop � 3`�� <br /> Busines i tuse�__Phone Number I p clots Sign tut Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I VX <br /> Correct: Incorrect: ( X a M P L E 1 2 3 <br /> ■ While Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />