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` 091 �205a019 <br /> = a;_ Waste Tire Suoey & Inspection Repor I+ Inspection Report Number — <br /> [�3i. .State B California 1 I 1 - 1088313 <br /> Cgrated asteMaage Survey Form - Page 1 <br /> California Integrated Waste Management Board I — <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: � j 9 L_� v O ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 0r61fri ch lhofts+rieS <br /> Physical Address ✓ ' I'-Jr i-(l,L S� <br /> asa5 S. �_-Y-Jop t <br /> I � <br /> SfrB21 <br /> Inspection Date-71 <br /> - — -- -- - � Time In Time Out <br /> city Spat^ 71P Code _ <br /> Business Rep 13- re{y ,matiL 3 Title P(CL 1t /�q/. j/—� i —i 0 AM0 ' 0AM <br /> 01 i D � ✓ ® PM <br /> s � Sayl't Ford'. P At)C(1,c��i rye -/"` ✓�_ _-- -- - - . <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) - (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t 1 �p <br /> ®Active 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> _. <br /> -0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ;HAULING 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 Date m m / m <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 EXT) <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/GIWMB 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 Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments // JV� � i� 1�c .� �i �� � � tit , I� - _(/l_ �'lbts <br /> yr or- f(.c �1^e Ser'y;Ce CQ_� oSa:Q <br /> erns VI e weA o ru —ph f( e w-4 -Fro cM *VT GG s ma g -e.d *1' eks <br /> ac , v-d l b_e rem ved once. Q bq iv>-0( � <br /> Inspection Form Included: W <br /> Comments Included: 0 — <br /> Business Rep's Signature Phone Number Inspector' Ignature Phone Number <br /> INSTRUCTIONS ON BACK Co r�ec-h ncorrect: MFEjXjAjWjP[LjEj. 11112 3 62081 <br /> White Cop :CIW Yellow Copy Operator Pink Copy:LEA <br />