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osisso�o4gs <br /> Waste Tire Survey & Inspection Report Inspection Report.Number <br /> Stafornia <br /> CMIMB 81i(New U/04) Survey Form - Page 1 Il - 10884 2 2 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID � � � � � � _ O � Inspection Type (Fill one) <br /> � <br /> Site suffix: ® Routine QRe-inspection QReferral <br /> Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: y0—LCpn. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �•c- Inspected By Inspector <br /> I �bl''c�.l �' ti r yslei� ��� I � � - D , <br /> Physical Address 1 l Je ad <br /> 11 ,45 K/- <br /> Street Al a�V ! 'C� 9 J�1 / <br /> 1 n - i Inspection Date <br /> City /lJ'A' State ZIP Code Time In Time Out <br /> Business Rep Title r0 1 / f��� AM � I I Q AM <br /> A-o-t- <br /> M is PM lires �. -_.:L._a - __r-_- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> (0 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - 1 1 . 1 1 Q Planned Q OTR Q End-Use ® Container . <br /> Business Type (Fill all that apply) <br /> Q'New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other t 1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS 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 Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q. 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / El <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 or <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 I C-IWMB 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 C-ompliance - No Violations <br /> Q 1 Q Other: § <br /> Comments o is [f1 Qi '!ig &IOh r ►''1,1,5 dabe. Yl 0-f;O—fX -Hv- fi//()wi�g <br /> h aDI --Frazier '[igL`f Oh '�D out, .& Ptndu cls 14 JkU c� Igs <br /> ;Q0 wlHj We sty fires attd- ew)oVe.d WAS Fk,l( tr�U GBP. <br /> �b iy!a�,i.l - �✓'►nsy i e vie <br /> Inspection Form Included: Q <br /> Comments Included. Q <br /> Business Rep's nature. Phone Number Inspector's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK •ones : Incorrect: IEIXIAIMIPILIEI 111273 <br /> White opy.C M Yellow Copy.Operator Pink Copy.LEA <br />