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07319040153 <br /> Waste Tire Survey'& Inspection. Report Inspection Report Number <br /> 011-w-m-BicallifomlaSurvey Form.- Page 1 1 7 - 10 7 3 5 7 9 <br /> {New04/04)grated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) ' <br /> Site Suffix: ,,3 p �f ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ScaM ra U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. U Inspected By Inspector <br /> I A t ht7rvtt�S �_f L{V ytf� Tt.C. i - / O <br /> Physical Address <br /> T11 LA_ <br /> Street <br /> Inspection Date <br /> In _ T <br /> City C� St-S2�IP Code Time In Time Out <br /> Businesfss Rep 7 Title Q AM Q AM <br /> ®PM m'm 0 PM <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 /> f ', r a <br /> ®Alive Q Passenger ®Generator ®Outdoor <br /> I O QClosed Q Altered <br /> GPS Latitude <br /> O Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> (� <br /> Longitude - I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 I <br /> Q New Tire Dealer Q Auto Repair ®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 l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT S1TATUS <br /> - — <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 /> Q Q 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 fir NOV or FXT) <br /> 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 t 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 1 Other. §. <br /> Comments <br /> 1-cr — --�l., ✓�r2lC.#i?1yi.S <br /> Inspection Form Included:Q <br /> Comments Included:Q — - - /'/-�"_='�'" <br /> Business Rep's Sig a ure Phone Number InspeMor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON.BACK IEIXIAIMIPILIEI 1112131 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br /> l <br />