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< 081280SO063 <br /> ;i. Waste Tire Survey & Inspection Report Inspection Report Number <br /> ;r Stale of MBCallfomla Survey Form - Page 1 i 1 - 1 01 .0 8 5 7 <br /> ctst stew oa <br /> CaI(romia Integlwue rated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 0 / Inspection Type (Fill one) <br /> Site Suffix: a:Z 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��,� �Qf[�Ih —� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. 6 Inspected By Inspector <br /> Physical Address <br /> I <br /> 1.24201 ,S' <br /> Street <br /> � 9 '336 Inspection Date <br /> �� <br /> City State ZIH Uode Time In Time Out <br /> Business Rep Title ED m 00 AM 0 AM <br /> PM m'm 0 PM <br /> Operational Status Tire Type Business Role. Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( I! „ rl_ <br /> Active Passenger ®Generator Q Outdoor <br /> m O Q Closed Q Altered <br /> GPS Latitude I I I Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 Other LAZ4-i ��/q�� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility NEINF.G.RZEMENNSTATUS <br /> V A HAULING AND MANIFE-ST REQUIREMENTS Q Notice Of Violation Q <br /> Q 1 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Extension <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 Date m / [T] / E[1 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F>C7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs fora years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 W In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 rQ L�a 0, ,4! .f CJLtQ� lie ���a/� Ldy" zlof'e.� <br /> rrc `' <br /> /- uQ f /Sr-� <br /> 9 �� /�� r�r� �'e <br /> Inspection Fond Included:Q //� -29 <br /> Comments Included:�= <br /> Busine Rep'siS gnature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACKC_o.rrec3:� In.correeta EX A M P;L I Eli I 1 '2 3 11 ® . <br /> While Copy CIWMB Yellow Copy Operator. Pink Copy LPA <br />