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073i204045S <br /> etc. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CFWMB 81a Surve Form - Page. 1 ( 1 . 10 7 3 5 2 4 <br /> (:IVYMB 181(Na.(NaOM04) Y <br /> Cellfomla Integrated Waste Management Board <br /> )art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• Iton Type ( -in <br /> Site Suffix: 10 I Inspection <br /> Re-inspection0Q Referral Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. { To0.�d�•� Cy,� .) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or facility Name' Inspected By Inspector <br /> �}�Y'ivn1e/r ICe_Gti!td—/_+"tt,to_IAF� 1 q <br /> Physical Address <br /> L/�acwlda_�ornf,T.. � <br /> �3.6�W•_I�,,u.u, P_tve.. l <br /> Street Inspection Date <br /> G/S 6L I <br /> City M�t�a � State 3ZIP Code Time In Time Out 0 PM <br /> Business Rep Title :F1 O AM O AM <br /> L-- -- S Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE),` i t I -2Jp <br /> I S Active ®Passenger I®Generator ®Outdoor <br /> f <br /> GPS Latitude I L_I J-Ll—��0 Q Closed Q Altered Q Q <br /> Hauler Indoor <br /> T I I0 Q Inactive ®Truck <br /> Longitude - _I I I —--I L] Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) LLL ill--- <br /> ®New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader 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 ENFORCEM NT STATUS <br /> -4"A iHAUL■INGlANDIM ANIRIE REQUIREMENTrS Q Notice Of iolatio 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. C^ompliance Deadline <br /> 10 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements. Date 1 <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/or NOV or FXV <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 t C-IWMB Enforcement <br /> Q O 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 o In Compliance.- No Violations <br /> Q Q Other: §, <br /> Comments J�v.L�s�T <br /> _, ¢ f�tbs—/A.. -� �•-- v7�— lu_f_Gl1►��'--• /�-fT/�r_cd�4�.t�L/ <br /> �S MG•_T_g.__��z_9_9�4r-o% l�ir«�d�_L%[,-,r��'c.C�/—� , � <br /> d , <br /> Inspection Form Included:Q X q U✓ <br /> Comments Included:Q /h Lf�+z, d''-0423 <br /> Busi ey Rep�Signature I Phone Number Inspector's Signature Phone Number <br /> I ( <br /> � INSTRUCTIONS ON 13AVK �11 ect: E Iorrest: IncorrXI A Ah P LIEP4 I 1 f:2I 3I 62081 <br /> . White Co :CIWMB 4 Yellow Copy:Operator Pink Copy:LEA ® ■ <br />