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09049040011 <br /> ne- <br /> Waste Tire Survey & Inspection Report. Inspection.Report Number . <br /> r� State of I31SIi(New I 11088348 <br /> Cgrated ,st!Manage) Survey Form - Page 1 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / G 151 _ 0 I Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection 40 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I&�K_ O Q. n _ Q CHP Q CIWMB Q Complaint Q Educational Visit ®Other <br /> Business or Facility Name <br /> IPhyC/'r f� /'� ��-}� D N//��``o Inspected By Inspector <br /> Address-/ �yl/Iy 1`Qi�/w� I yq] <br /> - v L J-'8'�D0 �Oy'ntby1 t gd . , mttk I�r-rlir[µ�•� <br /> L State ZIP Code <br /> Street <br /> (�-0/QI <br /> +Q �� ^ , q 5X09 I Inspection Date Time Out <br /> City O t / f O <br /> Time In w <br /> � <br /> Business Rep Title / O AMAM <br /> ®PM O y ®PM <br /> Tka,,,_N w _. - ),-Ot�l► ,_ <br /> Operational Status Tire Type Business Role Storage Type - <br /> I Ioo (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r r <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> GPS ! I, 0 Q Closed Q Altered Q Hauler Q indoor <br /> Latitude I <br /> -_t::c ' Q Inactive Q Truck <br /> Longitude - i i I ® Q End-Use Q Container <br /> Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q 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 i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility _ENFORCEMENT 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / 1:11 / m <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 'o FXn <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 Other. §. �` L ''f 1 {, <br /> CommentsQl�tr� a f� � Clr'dQGt-S_V"Q.57 Q —aJ�li(_( l <br /> W <br /> Lt -6r e's I rr,, 2T7re Pio m v <br /> 1 r-- l%s'F ` -�r't _1 seg s Seo(• to �e 1a 'ox <br /> Inspection Form Included:Q <br /> Comments Included:Q gra-89a 7 —L l <br /> : Business Rep' i6_ature Phone Number Inspector's P-19 nature Phone Number <br /> INSTRUCTIONS ON BACK E X A h4 P L E. 111213162081 <br /> . White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />