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r {. <br /> +'' t Imo•, L L ii <br /> 07312040446 <br /> `61",Aj Waste Tire Survey & Inspection Report. . Inspection Report Number <br /> State of Callfomia <br /> cIWMa,e,(New UMU4,. Survey Form- Page 1. 1 8 - 1 '0 7 3 3 2 4 <br /> callfomla integrated Waste Management 9oerd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Inspection Type (Fill one) <br /> Site Suffix: f L I 0 �� ��I / I✓I Q <br /> ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Loral �] If Referral,choose referral type(Fill one) <br /> Identifier: �/i/]rw�: _/ _ _ Q CHP Q CIWMB Q Complaint Q Educational.Visil 0 Other <br /> Business or Facility Name v75""� t/ <br /> � nspeded By Inspector <br /> lire <br /> Physical Address 3 Mo / <br /> 5-op? �. Il <br /> Street <br /> Inspection Date <br /> City J V ' Ste ee ZIP Code Time In Time Out <br /> Title <br /> Business Rep . F I Q AM Q AM <br /> L —vr f�i_ Br IQ/ItS.}f Qi({'1 L _QkAj 0 _j m Q PM m'm Q PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire <br /> ir�y TT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Count{Whole/PTE) ;f � � I f al <br /> 0 Active Passenger ®Generator 0 Outdoor <br /> . Latitude I- I I I � 0 Closed Q Altered <br /> GPS J t 0 Inactive Truck ®Hauler Q Indoor <br /> ® <br /> Longitude -.I I— I�-I 0 Planned ®OTR End-Use 0 Container <br /> Bu iness T e (Fill all that apply) J <br /> New Dealer 0 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. 0 Crumb Rubber <br /> 0 Service Station ®Hauler 0 Agriculture 0 Shredder 0 Other I <br /> .Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility I ENFORCEMENT STATUS <br /> VA j HAULING AND MANIFEST REQUIREMENTS <br /> ion <br /> O O 0 Notice Of Violat0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required or NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/Gill Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 19In Compliance - No Violations <br /> 0 0 Other: §, <br /> Comments R"Ne +y1c�yB-lf..__ r Y(.`�,(f�� *� r.a"f�.j j. ^ <br /> �0YV1R�1 !_1J Qom_ � `I „��,1�(QTtI YL(�(�C(A f[ lit1J IiLL(.j(-S ,tl�p, 11 � !r'►�la$ <br /> llt ►�t <br /> yo ✓i b2�7 t,S PL O_tC�l - dtoLr✓f� .SQ�'t'� ` <br /> r2-SS_ res Tft-41 <br /> Inspection Form Included:0 y��{y� [�/ <br /> Comments Included:Qius' <br /> /� C14 -2 '�" t-lF ess Rep's gn ure Phone Number Inspect s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrect: Ineorreet: EXAMPLE' <br /> '■ White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />