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__ ,, 09iS2050023 _ <br /> Waste Tire Survey &.Inspection Report Inspection Report Number <br /> State of <br /> ClwMe 181(Naw o California . <br /> SuMervey Form - Page 1 1 4 - 10 7 9 3 3 4 <br /> California Integrated <br /> Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: if L( ® Routine O Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -/V1i c11e 1(�'l 0 SPor±s_6*G—vi }f�>1dc' 11�1 _ 1 o 11TO–K <br /> Physical AddressVL_ �L <br /> 3�gS f4�( .fit- �� . - <br /> Street <br /> Inspection Date <br /> City J\ State Zip Code Time In Time Out <br /> Business Rep Title n 0 AMFOE <br /> ® PM 0 AM <br /> � � <br /> T�Kn Coons ® PM- 6(4, ' � -- <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) ! f S <br /> ®Active ® Passenger ® Generator (a Outdoor <br /> Latitude i I i D O Closed O Altered <br /> GPS l II Hauler Q Indoor <br /> _-� -- I �.__. O Inactive O Truck <br /> Longitude – 1 I I ,I I I 1 0 Planned ®OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair 0 Trucking Fleet 0 Government . 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection O Crumb Rubber ((�� � <br /> O Service Station O Hauler O Agriculture 0 Shredder ® Other rb*rSP0r45 Jcde.s / Cj <br /> 'LVi <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 10 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q_ 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 ® In Compliance - No Violations <br /> 10 1 Q1 Other: § <br /> Comments /S <br /> err PaOU1 0-- Ti r�1�t-��O�sa� .fog W -S-f-- ire (4QSr_MJ <br /> rnakki J;rms viewed Pt-z �jaas +cry �tat�Js I�t� �old�rt (� oelt��.fs <br /> ADT _a►�,iF�s �o�✓h�vi�u _/1/o V;o a,0fe Ltoca 1 111a sf� <br /> Inspection Form Included: <br /> Comments Included. �" Jy �f �v <br /> Business Rep's Signature Phone Number Inspect fs Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rec . Incorrect: (� 62081 <br /> VY EXAthhP 'LE 1 23 <br /> ■ While Cop :CIW B Yellow Copy.Operator Pink Copy.LEA <br />