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07312040469 <br /> rrr <br /> Waste .Tire Survey & Inspection Report Inspection Report Number ■ <br /> CstaIWt—c-1ifernd Survey Form - Page 1 11 - 1 0 7 3 5 3 2 <br /> IAB 187(Nov"041 <br /> carilomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D / / O / Inspection Type (Fill one) <br /> Site Suffix: C 1 7 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5, o[ .Y1 Cty. r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> tlnn��tt,, I <br /> Physical Address! ILi !q _ [�E/ ] i 3-, . <br /> -v_>�#_� I <br /> Street � <br /> Inspection Date <br /> City StategSZIP CodeI T <br /> Time In Time Out <br /> Business Rep Title /I 0 AM 0 AM <br /> C-21 0'- ¢' C m 0 PM m•m ®PM <br /> d— — — Operational Status Tire Type Business Role Storage Type <br /> r <br /> The Count(Whole/PTE) i I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> II l+ <br /> 0 Active Q Passenger ®Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS LULL- 1 I. jO Q Hower Q Indoor <br /> O Q In ®Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> �i- f FI <br /> �_ <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -------- ---— ..__.. <br /> V A ; A L Cy AND M (FEST REQUIREMENTS <br /> Q Notice Of Violation Q Ext nsion <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements <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 (Requued(or N•V or l7CTJ <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 Referred I 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 /> Q Q 1 Other: §, <br /> Comments <br /> -- - �nr�Za�t'fnY_l_—oY_�fi+'C fit"• �;-✓tc�-l.. I fy�G4� (_�ts.__�Ct <br /> _�rw_tu--�rtrn,cl.�cr-c�cu-r_-1�1c—C,tn¢`�,`r �Nca_�1-rt<s crc�,u�inf_No_��i S <br /> Inspection Form Included:Q _ <br /> D <br /> Comments Included:Q X _ �6$ b Z 3 <br /> Business Rep'6 Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �p r t: Incorrect: E X A M P L E 111213 62081 <br /> ■ White py CI Yellow Cop)Operator Pink Copy LEA ® ■ <br />