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V Od <br /> _ r. Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Clete B California" =I1 - 1088225 <br /> 4104) <br /> California lntegrated'Waso Management Board Survey Form - Page 1 <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D - O Inspection Type (Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: S. j -T-0 i�,iJ (-,O u ,j � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine or Facility Name (J <br /> Inspected By Inspector <br /> o o 3N _ I <br /> Physical Address 1 <br /> 1 �_[ <br /> 132 <br /> Street Q <br /> 572)C-4-- 16-, -- (6 Inspection Date <br /> 1 -- - Time In Time Out city State State—�!P Code �-;—� <br /> Business Rep Title IF ,1 l�AM j� I O AM <br /> L - I 1•j_J—_I o PM L�_� I'�_II 0 PM <br /> — "R� ----- - -0 � - --J OperationaIStatus Tire Type Business Role Storage Type <br /> /� <br /> ' (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .0 <br /> Tire Count(Whole/PTE) <br /> ' f Active le Passenger •Generator Q Outdoor <br /> '0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> --- - - - - Q Inactive Q Truck <br /> -- - - -- -- -— -10 <br /> Longitude - ! ! Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 NOV 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/CI.- B 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 Q Other: § <br /> Comments '�osw.*r h e�yt Oyu -� -t_ �'o r�✓vA�- Id <br /> c �iVS fJf��t�+• <br /> v✓l.4�I.i�� li,�.� �tJa +��o(_A.,�.�o�f�o�Cc_r_cte.��.•�3_-_esJ_c�• <br /> Inspection Form Included:Q <br /> Comments Included: , " - <br /> Q Bukine , r'S !44t�ure Phone Number Inspectors Signature - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK PT�m <br /> EXA M P :L E 1 ,2 3Whit Yellow Copy Operator Pink Copy:LFJ{ ® ■ <br />