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08038040305 <br /> r�rr WasteTire Surve & Inspection Report Inspection Report Number. <br /> w Survey Form - Page 1 1 4 - 10 7 9 4 2 5 <br /> cnvas tet(weDual <br /> caleomla Inbgattd Wpfa Manager-rd board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- p �7 D - O Inspection Type (Fill one) <br /> Site S.M.: I O i 0 Routine O Reinspection Q Referral O Observation <br /> Local _1%1 Referral,choose referral type(Fill one) <br /> Identifier: /O If <br /> OCIWMB 0Complaint O Educational Visit <br /> Other <br /> Business or Facility Name <br /> Per?s'k-6-7ruc� Leasing Inspected By Inspector <br /> Physical Address I - F/To XMarXJa 494&-�� <br /> Street Inspection Date <br /> City State Zip Code Time In ' Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m'm a PM m'm ®PM <br /> fou oral9ce - . <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). � i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> 46 Active O Passenger ®Generator Outdoor <br /> GPS Latitude <br /> O O Closed O Altered <br /> O Hauler O Indoor <br /> �� I---- �--� — I - -0 O Inactive ®Truck <br /> Longitude - -�- L L—I O Planned Q OTR O End-Use. Q Container <br /> Business Type (Fill all that apply) J <br /> .O New Tire Dealer O Auto Repair 0 Trucking Fleet . O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility JENFORCEMENT S1, WS <br /> V : A A INCD MANI S REQ I @ Q Notice Of violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (r?equ red for NOV or€X7) <br /> O O - ---- - - _.. <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers Q Referred 31 MB Enforcemene <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> ,01 O 1 Other: § <br /> Comments ROLef 7'ie—�O Jy'I%Q� �9is t��hauL�-is <br /> C` -1-s View-ed ir0/7 r.PT PJB-3 Caps Q 7_l� ol�sP �1 'l �i vr�d <br /> �r�S r�rnvKed�3 fir��nT rr�ee%—N0 tir�.r Olz�P�-vQd Dr�S/�Q�fih�e D� <br /> Inspection Form Included:O <br /> - Comments Included:O- -- fe <br /> Bu�. Sign.tre Phone Number Inspectoes Slgnatu Phone Number- - 62081 <br /> INSTRUCTIONS ON BACK Correct: Imeorrect: EXAMPLE 2 3 <br /> 1 <br /> . - White Copy.CIWMB Yellow Copy Operalw Pink Copy.LEA <br />