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� -,; 0920300039 <br /> Inspection Report Number <br /> H0 <br /> Waste Tire Survey & Inspection ReportH0 <br /> state of California <br /> California lntegratedWasteManagementBoard Survey Form - Page 1 I1 - 1108. 49.4 . , <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �I II —� Inspection Type (Fill one) <br /> Site Suffix: ( � 1 J t o I 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local �?_��_1 I If Referral,choose referral type(Fill one) <br /> Identifier: ( J u,(1 W ( I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L�_qbo�._.P�o AVe, I <br /> Street I <br /> I—�C 95� , I Inspection Date r„ �1's I / d G 1 <br /> Ciry � Stato Zip Cc::a Time In V� Time Out 1 <br /> Business Rep Title �I AM F-1 <br /> 6,j AM <br /> r vt� t L JPM �AIPM <br /> � `— -- 1- �`- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all.that apply) (Fill all that apply) (Fill allthat apply) <br /> Tire Count(WholelPTE) <br /> ®Active Q Passenger 40 Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> e <br /> GPS Q Hauler ® Indoor <br /> _-__ 0 Q inactive ®Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair lb 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 L I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATU+S <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice - Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 Req iced for NO or FXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q t. 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q eferced/CI M Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators JOE nCompliance - No Violations <br /> Q 1 Q 1 Other. § <br /> Comments t <br /> 1_-W c i a (AS5 (A-C �OAoWIn <br /> a�t8 1�_o� a�laa_ II3jo6 ql9 og _JL_off to o� fa�o� +L 4 0q. <br /> Inspection Form Included: Q / ,— <br /> Comments Included: �"� �- ��$.S9j �JmW I <br /> usiness Rep' natur / Phone Number %nspeor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK •OEM!- . Incorrect: X A M F [L E.j! 1112L3 <br /> White C py.C B Yellow Copy.Operator Pink Copy.LEA <br />