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08245040025 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> a� Stataof 81IIIfcmle Survey Form - Page 1 15 -_ 1_0_7 9 3 0 2 <br /> CIWMB 181 stew analis) <br /> '. Callfomla Inleprated Waste Management Board -- <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 a Inspection Type (Fill one) <br /> Site Suffix: O 3 / 0 Q •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> H Referral,choose referral type(Fill one) <br /> Identifier: �GJIL c,64 ,�, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I �!6 it GUS G� I <br /> Street <br /> c�"D�v�s+sc C.7j 9Se� I Inspection Date <br /> City State ZlP Code Time In Time Out <br /> Business Rep Title- *-AM AM <br /> / 3 O PM O O PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Whole/PTE n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count <br /> ( , ' 1 C7 ®Active ®Passenger 0 Generator 0 Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered <br /> j J 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — j IO 0 Planned 0 OTR 0 End-Use ®Container <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other. I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility RENFUGERREMENT STATUS <br /> V A HA LING AND M IFEST EClUIR -MENT 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. -ompliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1:11 / 1:11 <br /> / <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Req fired for OV or <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - o Violations <br /> 0 0 1 Other: § <br /> Comments aGir°lj`�LY `CLJ[�F+' r //�� TCtle4✓C 9�/�, �L �S' <br /> 1�/•2�d�� yuan /?�,� . <br /> _ 7 L— <br /> 4V�0 <br /> Inspection Form Included: <br /> Comments Included:0 <br /> B s Rep's atura Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ONBACK Correct:1101Inco re t: I I X I A IM I P I LFE' 1 Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />