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I <br /> - - 08038840312 <br /> =«t Waste Tire Survey & Inspection Report' -inspection Report Number <br /> era <br /> ;r <br /> state e (N.04104) <br /> ChVMB1$i781(New - Survey Form - Page 1 - 11 - 1 0 7 3 3 6 7 <br /> c"ifomia Integrated.Waste Management Board <br /> Part A-Survey_- _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ O / Inspection Type (Fill one) <br /> Suffix:Site (� ®Routine .O Re-inspection Q Referral p Observation <br /> LocalG�� r If Referral,choose referral type(Fill one) <br /> Identifier: . c_JI^-•V To C� I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i Inspected By Inspector' <br /> Physical Address <br /> 1 0 OL/ �. �obe Awe• I <br /> Street E <br /> C+ s 33 G I Inspection Date O r r D X <br /> city State ZIP Code Time In __F] Time Out C� <br /> Business Rep Title O AM O AM <br /> QPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE): 1 I �t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that.apply) <br /> t f .. f l_ 16 r ®Active a Passenger a Generator Q Outdoor <br /> D Q Closed Q Altered 0/4 <br /> GPS Latitude ,� Q Hauler Q Indoor <br /> �1, 0 Q Inactive Q Truck <br /> 1-717- 11 <br /> Longitude - 1 1 1 Q Planned Q OTR Q End-Use : Q Container <br /> Business Type (Fill all that apply) _-_--_- <br /> Q New Tire Dealer Q Auto Repair p Trucking Fleet p Government p Retreader Q Dismantler 0 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 ®Other A( �/,VY`E <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF-ORCE_ME_NT STATUS <br /> V . AIMLIN-GYNN-91M MMEES01100110MR-E EN <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice of Violation Extension <br /> Q <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Ueadiine <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§16459 -Responsible Entities-Complying with Manifesting Requirements Date m / m / <br /> O O 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXl) <br /> I <br /> Q I O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 ® n -omplia ce No Yto atlons <br /> Q Q Other. § <br /> ts // �f <br /> Commen -- Arj- -)-�- - -da—- "J� WaS " e .T L1 S <br /> ` o <br /> 6Ukiue e� ►�.�.1�-s.__. , f ►gip. -- .e home On-p— -f1' <br /> cid -tL69S - D r of—t raef zrs h '.s <br /> 011 <br /> Inspection Form.Included:Q J <br /> Comments Included:Q <br /> Busine s Rep's ISignature Phone Number Ins or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I&JAMIPILIE1 111213] 662031 <br /> . WhNe Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />