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_ x823404.0298 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> Ci nB181(No* I1 1088160 <br /> C9rated 181(No* <br /> Survey Form - Page 1 <br /> Catifomia Imegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> + TPID- Inspection Type(Fill one) <br /> sit. . <br /> y2 g 2 019111 © / •Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 5q„) �Og�a.tinl (.Ott J f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phya Ta�_,"y5_ [�E <br /> s eai I Address '� /ZI TAu ��,4 <br /> I <br /> 1603._ s. <br /> Street Inspection Date <br /> i S;-o�lc�, __ _ C A ___ I <br /> Cit; State ZIP Code Time In Time Out <br /> Business Rep Title I ,F y 0 AM. 1 0 II AM <br /> �f'`� I 0 PM <br /> ' <br /> ..11GVi/kl-_Ar�/a/ersg>+--- -- -_" 6fe-.-------- - <br /> Operational Status Tire-Type Business Role Storage Type <br /> Tire Count'(Whole/PTE) S /2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t TJ le Active Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ! Q Hauler Q Indoor <br /> ..: .D Q Inactive Truck <br /> i <br /> Longitude – i I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet i 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E_NF.O_ftCEMEN1T STATUS <br /> V A :HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> .0 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 Entities Complying with Manifesting Requirements Date <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 (Required for NO V or EXT) <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 Q 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 1 Q 1 Other. § <br /> Comments <br /> �oLe�rN+t <br /> /_.» <br /> ��ss�Lr�..� �iY� Lr�..�..�... . f�.aar�•�1� <br /> Inspection Form Included:Q <br /> "_—�Zhone <br /> Comments Included:Q—Busi ess Rep' Si .Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK orr t: X a M P111213 62081 <br /> ■ White Co :Cl i Yellow Copy:Operator Pink Copy.LEA ® ■ <br />