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07313040178 <br /> Waste Tire Survey Inspection Report: (nspeetion.ReportNumber: <br /> s : ..■ <br /> state nromla <br /> [WMeer7c81aiNewe4J04) .Survey+Form - Page 1 1 . 3 - 10 7 3 5 5 0.- <br /> Califomle Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection-Type O Inspection Type(Fill one) -- <br /> Site Suffix: <br /> 0 Routine Q Re-inspection. Q Referral Q Observation <br /> Local If Referral;choose referral type(Fill one). <br /> Identifier: p <br /> 5gnn a +^ t/yru.-� Q CHP Q CIWMB Q.Complaint Q.Educational Visit Q•Other <br /> LBusiness or Facility Name <br /> Inspected By Inspector <br /> I <br /> Physical Address <br /> �LLO I�_�-1wY-I z-� <br /> Street <br /> I Inspection Date � U / ' 8 � p •� <br /> c-A -s t3 3 rp Code Time In Time Out <br /> Business Rep c Title OAM O AM <br /> L__ ?�./Kt Dyl S L_S. _Y.YO( t m•m 0 PM ELI:m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I j (Fill one only) (Fill all that apply) (Fill all that apply). (Fill all that apply) <br /> Tire Count(Whole/PTE),I�I1- 71 JI Sq <br /> Active ®Passenger ®Generator Outdoor <br /> FT <br /> � , l O Q Closed ®Altered <br /> GPS Latitude W, I Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned' ®OTR Q End-Use Q Container <br /> Business Type (Fill all'that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet le Government Q Retreader O 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 Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT S,TATU_S ___ _ _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q Q Notice Of Violation Extension <br /> 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 (D 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / LE <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2:1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FX n <br /> O O 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 t CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 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 M I <br /> �--�- t�-„�'— t , <br /> Q �L�.6-�-. Tcc1A44 1���L���. f n.S_S�_C�T_G_Ly uwnn�,•,.T,.i.,t`c..c --- <br /> �GCAIS4 at 1-`olm fX464'tV r - _afv Sa 41'k4, JVIV tn'olea��►s- - <br /> Inspection Form Included:Q �� � �•�—o b z:3 <br /> Comments'Included:Q - - — - -- <br /> iusiness Re 's Signature Phone Number Inspectors Signature. Phone Number <br /> `` 62081 <br /> INSTRUCTIONS ON BACK Correct:l' Incorrect: }f.RM P L E 11-1213 <br /> ■ <br /> Pink Copy.LEA <br /> White Copy:CIWMB Yellow Copy.Operator ® ■ <br /> L i.' <br />