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ifl14�040070 <br /> Waste Tire Survey & Inspection Report - Inspection Report Number ■ <br /> rrt State of California ,' I <br /> CFW 1(New nage Survey Form - Page 1 I 1 - 114--39- 78 <br /> California Integrated Waste Management Board <br /> ,art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: LF,51 a--�15- Iz I l I i [�El_ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: San 5oc,�c��1� CJIIY{• ,/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll Inspected By Inspector <br /> Physical Address I T0:11 A_tJGrUO-a CJU <br /> L��f.�_.__+,re►3").��- _J J- - <br /> Street <br /> �7�y� Inspection Date <br /> +C4 C -A - �A �5�03L Time In Time Out l <br /> City State ZIP Code j <br /> Business Rep Title / �] r— O AM f O AM <br /> l O� ( I �� I®PM l d PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ' <br /> ' ' I Q Active Q Passenger Q Generator . Q Outdoor <br /> Latitude l0 ®Closed .Q Alterekd #/A <br /> GPS Q Hauler Q Indoor <br /> Q Inactive Truc <br /> O <br /> l� <br /> Longitude - i I 4• I I I Q Planned Q OTR. Q End-Use Q Container <br /> Business Type (Fill all that apply). <br /> 'J New Tire Dealer Q.Auto-Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel. <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber r I <br /> Q Service Station. Q Hauler Q Agriculture Q Shredder ®Other LV��.D �✓L <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORGEME1NT�STAT,U_S <br /> V A�'.HAUUNG AND &&FEST REQUIRI EMEN�TS <br /> 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 DeatlIins. <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 (Required for NOV of EX7) <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 eQ Referred t 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: § L /� d - <br /> Comments �11a,� 1�f ' AJP L//dJ LI?'JS CY <br /> 0,.�1P1T L—co� C'16 -/C-- 77�zY( 4� l�oZ UL <br /> spection Form Included: Q <br /> Comments Included, Q <br /> Business Rep's Signatur PhoriejNumber e s Signature kPhone Number. <br /> INSTRUCTIONS ON BACK Corse 61•, In •rrect.�G E�X A M P L 1 2 3 62081 <br /> 1'ao^►' �u :6�LY av�uri!al <br /> White Copy IW B Yellow Copy:Operator Pink Copy.LEA • <br />