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Waste Tire Survey & Inspection Report __inspection Report Number ■ <br /> ■ :1i CN ! 2 . 1 0 7 3 31 0 a <br /> State <br /> (No. Survey Form - Page 1 <br /> eatifo, a integrat*d waste Nanagemsm Board — T------ <br /> Part A-Suroe BLUE gR BLACKNK PEN <br /> Business Profile _ Inspection Detailsl7r}n4 i <br /> TPID- _ ( I Inspection Type (Fill one) ��t419 <br /> I 1 I I <br /> Site Suffix: 81 $ 1 I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local A�► -- If Referral,choose referral type(Fill one) <br /> Identifier: �t7JYW f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PICJVSjzj RT&CK_l &JS)N_G Cp, �"J Lv�v�vf <br /> I- - Q-a _P-ESCAEap hVE -j, - -7 <br /> Street O� Inspection Date V J I I <br /> II TPACY CA qs3 _ <br /> C,ry — - —�- State Zif'Code Time In Time Out <br /> Business Rap Title O AM I 1, O AM <br /> _ - .Y ,!"v v"_, 0 PM � _ '1 _ O PM <br /> V i <br /> �` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill an that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> ,O Q Closed Q Altered <br /> GPS Latitude I i Q Hauler ®Indoor <br /> - IQ Inactive ®Truck <br /> O Q End-Use Q Container <br /> Longitude - i Q Planned Q OTR <br /> Business Type (Fill all that apply) _- — J <br /> Q New Tire Dealer Q Auto Repair 4 Trucking Fleet Q Govemment 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> ° 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible EnttUes Complying with Manifesting Requirements Date <br /> M / m / <br /> Q0 14 CCR§18459.1-Tire Program ID Number from ClWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required forNOV or EXT/ — <br /> ;Q ° 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I 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 /> ° to 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations <br /> Q Q Other. § <br /> Comments Lt�11lL CM---'N-5_cWe,`�iiki f <br /> Ferre bb -l� Foof/l ye�ArDly In ►tea - i2SjS�sIf CCL 4 TPr�`ra8e70-o! A45yieWa) <br /> Oh +navu�esfs P 9- <br /> AW— <br /> G4 _ os �fi� , mat ?Ply af��e <br /> Inspection Form Included: <br /> °� -sS9� _ yt��99 <br /> Comments Included:® Bu n Rep's Signature Phone Number Insp or Signa a Phone Number <br /> �-/ 62081 <br /> ■ INSTRUCTIONS ON B CK Correct:* Incorrect: (� l�J EIXIAXP I L 1 2 3 ■ <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br />