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Waste Tire Sur*y & Inspection Report .ispection Report Number <br /> state cram Califomia Survey Firm - Pale 1 i 7 - 1 0 0 6 6 9 6 <br /> CNYMB 181(New 04104) Survey BLUE OR BLACK INK PEN <br /> Part A-Surve <br /> Business Profile 2 Inspection Details <br /> TPID- p -T-TInspection Type (Fill one) <br /> Site Suffix: r Z f 3 ` O Routine ® Re-inspection Q Referral Q Observation <br /> Local _ <br /> //^^ <br /> Referral,choose referral type(Fill one) <br /> Identifier: �cz, �DG.jh;_ Lrr+„� y � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name [ Inspected By Inspector <br /> ITF1e-k-- _ p� (I I _ <br /> Physical Address <br /> i —a'CA 2-? Cir <br /> Street <br /> Inspection Date Ll� <br /> ciLt State ZIP C�b�5Z, CA Q 5 -7j <br /> Y ode Time In Time Out <br /> p AM Q AM <br /> Business Rep Title <br /> © FPTP1 QPM [E : <br /> QPM <br /> t �11r� t <br /> Operational Status The 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)' l S711V p <br /> ®Active ® Passenger ®Generator ® Outdoor <br /> PS Latitude ���--1 I -- ^�__ o O Closed Q Altered <br /> Q Hauler Q IndoorG0 Q Inactive Q Truck End Use Q Container <br /> Longitude — _T Q Planned Q OTR <br /> Business Type (Fill all that apply) iii <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader ® Disman!!er Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date <br /> 0 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or DCT) <br /> O O —Y <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ — — <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> Q Other: § JJ <br /> Comments <br /> 5 rl� L..q� r9�c�. e 15—v— <br /> �c5�t. <br /> 1"� C7�_� L.^•I n f^S' tirC s + �G l�l �— -�?�� <br /> Inspection Form Included: Q thon, <br /> 401 <br /> Comments Included: (� —Business ep's Signature Number lns�pture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: !r X A M P.WEI 11 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />