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08129040867 <br /> WasteTireSurvey & Inspection Report Inspection Report Number ■ <br /> ClWatdWasteMaage Survey Form - Page 1 1 1 9 - 1 0 7 2 8 2 2 1 <br /> CalNomia Intepratad Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L�/ O / Inspection Type(Fill one) <br /> Site suffix: I '' I I � � 1. S I 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tj VN C-,bU 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name LL Inspected By Inspector <br /> L_�L AT_ �+ T2s S'Llo� � q - 1 O l t-IAP�IE1�1 <br /> Physical Address <br /> Srr�'' <br /> Inspection Date <br /> city State G4 Q52o5 <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title EUOAM O AM <br /> O PM m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> j.3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Active Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 1—I J i -�— I I 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - I ,I I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 10 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 /> 10 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> otice . Violation <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 N 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C^ompltance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 (Required for NOV or EXT) <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 0 Referred I 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 Compliance No Violations <br /> 0 0 1 Other: § <br /> Comments RoG,TrjE %NsPnU,J off iters Vp7 —Tff�S f4[i_/cfJ/ �S AISo <br /> I'l'-iZ/5-o I oa ✓_ <br /> Gvtsr£_rie�H•4uif,Q T�t,sF.s_u'I� �� Lv��e � s PFJ .+s <br /> -5 <br /> 4_ . <br /> w�sr>r rates .�,vd�1au�5 7H�S_hredded <br /> alaf t�wdF4__. k>Wdsrs_�` mac. � VfEwEd- do V0OM61s ez_Ca�c���ts�tl�r�l, <br /> Inspection Form Included:0 �9 <br /> Comments Included:0 <br /> Busine ignature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC correct•. Ineorret- . IEIXIAIMIPILIEI 1112131 <br /> ■ Whit opy:CIN Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> I , <br />