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09210444254 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B California FI1 - . 1088492. <br /> Cgrated a3teManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE-OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection D � � � Inspection Type (Fill one) <br /> Site Suffix: 0 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Loral — If Referral,choose referral type(Fill one) <br /> Identifier: CSV 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name u <br /> Inspected By Inspector <br /> I Ex 13 <br /> Physical Address � — � � � L���.� <br /> LR3� <br /> Street <br /> Inspection Date <br /> � <br /> city State ZIP Code�——` -` Time In Time Out <br /> Business Rep Title AM <br /> ®AM <br /> 101 ' , / I0I0PM ! .l � ' I 0 V� 0 P <br /> .Operational Status Tire Type Business Role . Storage Type <br /> Tire Count(Whole/PTE) . (Fill one only) (Fill all that appy) (Fill all that-apply) (Fill all that apply) <br /> t ' 1 Is Active 0 Passenger 0 Generator 0 Outdoor <br /> — —_l -'— - -- 0 0 Closed 0 Altered <br /> Latitude <br /> GPS J-, _-_ —_ _I I 0 Hauler ®Indoor <br /> --Q 0 Inactive t®Truck <br /> — j- 0 End-Use 0 Container <br /> Longitude <br /> I I I j I 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government O.Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other I/yd�at�fGrim <br /> CG <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 01MMjW,ULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 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 for NOV or FXT) <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 0 Referred/ -11111 MQ 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 In C^ompliance - No Violations <br /> 0 10 1 Other; § <br /> Comments flC,��lYl�, Il1S.OP_ �Yl OCm e cl'L—A L�l—CKAi1C– 4✓!U -fk'1 e-� O_(• _& <br /> Inspection FormIncluded: 0 or <br /> Comments Included: 0 <br /> ure Phone Number In p cto s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C"�M <br /> X A M R ' 1 2 3 <br /> White CoYellow Copy:Operator Pink Copy LEA <br />