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� ^a <br /> 08066040047 <br /> 'L"HN Waste Tire Survey & Inspection Report 'Inspection Report Number ■ <br /> rr StateCIWMB OfCtg7dlifOm(Newla04/Oct) Survey Form - Page 1 11 1 - 10 7 9 4 5 5 <br /> celifomia Integrated Waste Management Board <br /> )art A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q -/ Inspection Type (Fill one) <br /> Site Suffix: I ;2I l 3 y l O T O ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: I ,pn —A� 0 CHP L 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By In/s/p►temctlour <br /> Physical Advoc- <br /> . <br /> nn uu <br /> Street <br /> Inspection Date <br /> n A <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> m <br /> m' ®PM ®PM <br /> Tom, ;:ro- --t t_b. ►�I tr_•Coc"'Li <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE)' j T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger 0 Generator 0 Outdoor <br /> GPS LatitudeI I�— — 0 Closed. ®Altered O O <br /> f Hauler Indoor <br /> - <br /> 0 0 Inactive ®Truck <br /> Longitude 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type '(Fill all that apply).. N/A _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet I*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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 I 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 /> Q —dr_ts(�casF-�`�w.—mac.—'�'k•c o_�c+7ta.��L.1_L W._t,�rf—��'°—'2�u.`a_r�— <br /> pt=c�ccc��P— <br /> _� C�ta.al�.tls_tvna/ y„riJE+-uvtc�s. /_I/o—flus—��ot Crn-u"k . �i_rtr /_twKvv+co� <br /> —�r_rmh�if_rcrk-_��i�— /1/ o�o_Lu.h�-c <br /> Inspection Form Included:0 ��6 gra ye <br /> Comments Included:Q <br /> X <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 0 I I I II I f 1 2 3 1 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �. X' A M P L I E: I I, I ■ <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />