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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> See of California <br /> C WM8 (New 04104) <br /> Californe In egrat df81 Was e Management Board Survey Form - Page 1 Il - 1088079 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• \ Inspection Type (Fill one) <br /> Site Suffix: 1 q $ y ( 46 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SLI,n -0c q1,n Cdll u 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> � Lb� _ o j� <br /> Physical Address <br /> 6 L9)d S�P�n (�- <br /> S �y /� o��� Inspection Date y � 1 � � b Q <br /> - 40(� CA i Time In ` Time Out I <br /> Business Rep Title e 0 AM 0 AM <br /> 1"11 ln2 �V 0 P - 0 P <br /> M <br /> `J <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 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 6v�VOA 4 61i,,eA A Q'-kcuts S <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 100- PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 10 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> m <br /> �0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data F / / <br /> I0 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 /> 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 Referred/CIWMB Enforcement <br /> 10 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 10 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators le In Compliance - No Violations <br /> 0 0 Other. § <br /> Comments f Q CA S L`QSe �v <br /> Inspection Form Included:0 rr Q t� <br /> Comments Included:0 One N J�er p <br /> Business Rep's Signature Phone Number Insp or's Signature hone Number <br /> INSTRUCTIONS ON BACK Co ct: I correct: 6zos1 <br /> t X A 11. <br /> ■ X — L E 1�2 3 <br /> / �;.'" Pink Copy LEA ■ <br />