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I <br /> 0SR87 <br /> Waste Tire Survey & Inspection Report.. 0�0004 ■ <br /> ¢n. <br /> _ Inspection eport umber <br /> State_Fate,Cdlfomla - Survey Form - Page 1 I l - 1 0 7 9 .1 8 8 <br /> CMlMB tat(Naw 04104) Y <br /> Califomia Integrated Waste Management Board <br /> Part A•Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( O 2 - O Inspection Type (Fill one) <br /> 13 1 <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: : 5an UOQQUt n County Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ��oo_d�X. resS 1 ,.y I <br /> Physical Address PFN <br /> _ lq�m <br /> LJK 10n( L.UCQS_I <br /> Street <br /> Inspection Date <br /> city .r_o_� C.�+ q.533o. <br /> City State ZIP Code Time In Time Out <br /> Business Rep L Title :F1 IQ AQ AM <br /> Masa. r m O PM M — O PM <br /> Operational status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' 0 Active Q Passenger e Generator 0 Outdoor <br /> GPS �0 0 Closed Q Altered <br /> • Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _1-L Q Planned I Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) l <br /> Q New Tire Dealer Q Auto Repair 0 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS ' <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> i <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 / m / m <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 for NOV or <br /> Q Q 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/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 e In Compliance •'No Violations <br /> Q Q Other: § <br /> Comments <br /> _ �.Qv�I(tA ► smec�ior� ep.r�"c�rn�erl is � e_.��'►'ut•�olloc.a� ,,acmes r,ot'�a <br /> mac 1\ �t�es �l2etTi_r_e $scionolt_��r� or u�s�s -�ife_Io_ou1Lt2�— <br /> C:-f!r �nG�r,i-�es�i_;�ete_re'rq�r2c�, <br /> t�oy lot a�inns or o a�e.d . <br /> Inspection Form Included:Q Ca0`I <br /> Comments Included:Q W� tV — �_ <br /> Busines p's igna ur Phone Number Inor's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect orrect:X R�, 9f X A M P[LIErI1 ,213 62081 <br /> ■ White py:CIW Yellow Copy Operator Pink Copy:LFA ® ■ <br />