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08129041085 <br /> trr- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr StatMB 81(N.. <br /> Survey Form Page 1 11 - 1 Q 7 2 8 1 5 <br /> "' yet(Naw oaoal <br /> Callfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �r/1 / Inspection Type (Fill one) <br /> Site Suffix: ��S t/ O tD K-J] Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1.'5A,J IJ Q CHP 0 CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name �. <br /> Inspected By Inspector <br /> L_ fL�iif-/ / c t�fu^� _t�ices-i 3 / <br /> Phys ca Ad re <br /> O <br /> ss 9 <br /> L/ <br /> Street 2 I <br /> Street Inspection DateLN Ji _57 , <br /> City Stale <br /> CCV <br /> ZIP Code <br /> Time In Time Out <br /> Business Rep J- Title 0AM Q AM <br /> m0 <br /> PM 1='m 0 PM <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) <br /> r ° - Active Passenger i Generator *.Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude I- [j.I---I- - Q Hauler Q Indoor <br /> ll r r T O 0Inactive Q Truck <br /> Longitude - I I I I I Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Agriculture Q Shredder Q Other I J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityEN.5 RCEME�N1T S1TATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / 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 IVOV or EX>) <br /> O O - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-IWMB Enforcement <br /> O O 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 <br /> Inspection Forrn Included:Q 2�9 <br /> Comments Included: - - G <br /> Business Rep's Signa4ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ec � ncorrEXAAP LEi 'z 3 62081 <br /> ■ While Cop CIWM Yellow Copy.Operator Pink Copy LFA ® ■ <br /> I <br />