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08206040088 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> afateei8l(emla Survey Form - Page 1 16 - 1 0 7 9 2 8 6 <br /> clwMe tel(New 04104)callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> I TPID- ' n A n - D Inspection Type (Fill one) <br /> Site Suffix: L ( `T 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ��� Como nj Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By. Inspector <br /> I_T N c. �C.� s �• H�� a� 2 ,� <br /> Physical Address / < ✓ LTAu( � <br /> i 3909 N , We,,r t - <br /> Street Inspection Date <br /> �15;-b GF <br /> City State Z!P Code <br /> I Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> —- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ! i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> I ' J Active I).Passenger 0 Generator 0 Outdoor <br /> Latitude I I.LO O Closed Q Altered <br /> T <br /> GPS I I I <br /> � I O Q Inactive Q Truck O Hauler Q Indoor <br /> _ _ <br /> Longitude _. , I Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 111 <br /> Q New Tire Dealer @ Auto Repair Q Trucking Fleet Q Government Q ReVeader 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility_ ENFORCEMEN�TrSTAT�US�, <br /> V AI HQULINGA MANIFEST REQURPM ENIT. 's <br /> Q O I PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Requi ed for NOV or EXTj)a <br /> Q .0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years "W <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 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 O Other: -§ _t L I . I <br /> CommentsiN�_%nJSPLc �+'J--QYi7_10 <br /> % j—Lst.c�.Q�.14� 1�4._g. l�^�,•��R-�S dao- %�w•� r ij�—� ca.D 4-%10,a— <br /> `_La,�.Q�!/ .��✓(i t D(_vr►'a�nr.r o2 ��cn,S� <br /> Inspection Form Included: <br /> Comments Included:Q - - — --- <br /> Business Rep's Signature ��Phoneumb r Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C-o ect. correct: lEX A IM P;L E I ;2 3 62081 <br /> ■ <br /> Whit <br /> e Cop:CIWM Yellow Copy Operator Pink Copy:LFA ® ■ <br />