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08206040085 <br /> ru_ <br /> Inspection Report Inspection <br /> Waste Tire Survey & <br /> rr State8181lomla $urve Form Page 1 1 7 - 10 7 9 2 7 9 <br /> cgmte 161(New oaoa) y <br /> Gallfomia Integrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ Inspection Type (Fill one) <br /> Site Suffix: F01, 11D 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^7� �l If Referral,choose referral type(Fill one) <br /> Identifier: jj ,/Oh=µ��J Cq erJ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name D Inspected By Inspector <br /> I C�.s Sc k�,..4-6 <br /> Physical Address <br /> Street <br /> `� 9S2oZ I Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title/ Q AM 0 AM <br /> EE <br /> .m O PM [1].m O PM <br /> —— Operational Status Tire Type Business Role Storage Type' <br /> I <br /> Tire Count(Whole/PTE),, <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t 2 I d � <br /> 0 Active •Passenger 0 Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> —II—JI I ID Hauler Q Indoor <br /> -- Q Inactive 0 Truck <br /> � I O <br /> Longitude — i. I Q Planned 0 OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 /> VA_L__gIAR60INMYAND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 <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 (Requi ed for NOV or FXTJ <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/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: § <br /> Comments <br /> �.r,•..,�*-r_.�-ria-.-.�.�..a�—yr�,�/ _,t�O !/,�l�.,y4�s e► ��,_.,s <br /> Inspection Form Included:Q !f J <br /> Comments Included:Q— V � — r�"' �"� 9te t;3 <br /> B is Rep's !gnat re Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA C rrect: correct: MIEIXIAIMIPIL <br /> ■ White C py CIWM Yellow Copy Operator Pink Copy LEA ® ■ <br />