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1672640 50026 ■ <br /> rtt <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> r�rr Stated California <br /> CM'Me, M-9-0& Survey Form - Page 1 (_l_. 5 . 1 0. 7 3 3 0 5_� <br /> Galifomia Integrated Waswas4 t Board -- ' <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- T ) h 1 Inspection Type (Fill one) <br /> Site Suffix: r_I 3] I OI I � ' - v 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: C �OQ 'ti _ ] Q CHP (D CIWM8 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physl alAddJress �/J <br /> I�_l0o vV r KAt )y _1 - <br /> Inspection Data <br /> 95.3_72 —) Time In Time Out _ _ <br /> Mate Zip Cog: <br /> Business Rep Title '[T '1�: <br /> 0 AM <br /> � I p PM 0 AM �_ J O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) u t) D <br /> 1 ®Active 0 Passenger 0 Generator 0 Outdoor <br /> 'D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> _ - -- - Q Inactive ®Truck <br /> Longitude - 'I I Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantier 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 (0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vi A HAULING AND MANIFEST REQUIREMENTS ®Notice Of Violation Q Extension <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires l <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> ©/ © / IiN <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 (RequiredlorNOV or DCT} — <br /> O @ 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 pliance - No Violations <br /> Q Q Other. - <br /> �� <br /> Comments <br /> _u!�Olcr�, <br /> rpr�ppr� ivr SGtt ��0_l� i�i.� 5_�Qua1 — �I� <br /> it r,��1_ (i.�1 Ary �5 ✓°pmt tend wl—pit t-pPerr� <br /> Inspection Form Included:Q l p f� '�yia8 <br /> Comments Included:is', b ��Y ""Ph <br /> I siness Reps Sig u Phone Number I sp tors S g elute Phone Number <br /> Correct: incorrect: ��EIXIAIM�P LIEI �1I2�3� 62061 <br /> INSTRUCTIONS ON BACK ' <br /> . White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA �� . <br />