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08129040865 <br /> Waste Tire Survey $ Inspection Report Inspection Report NumberSute ■ <br /> C"AlfCalifornia Survey Form - Page 1 _1 3 - 1 0 7 2 8 1 7 1 <br /> CNVMB 191(Naw 04104)Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: LI 5 2 8 I LI "I O <br /> Q Routine Q Re-inspection Q Referral 16 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physicaldre s /—�T ' 1k] _ <br /> Street l�� Ic <br /> I_STo� a 95zos Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep Title <br /> IT]:mOAM .m AM <br /> Q PM Q 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) e f I t <br /> 0 Active 0 Passenger 0 Generator •Outdoor <br /> ' I I 10 Q Closed Q Altered <br /> GPS Latitude I -1-L-1 <br /> -(— f --_1--I� Q Hauler Q Indoor <br /> _IL—_1I _ I_ 1_ _ Q Inactive Q Truck <br /> Longitude - I 1 1 I I _ 0 Q Planned Q OTR Q End-Use Q Container <br /> 111 I 1 �- -- <br /> Business Type (Fill all that apply) <br /> •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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT SITATUS <br /> VHA LING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice OT Violation ension <br /> Q Ext <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 00 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXn <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/C-IWMB 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 In C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments Pa.-7-iiu£ / <br /> a.S /.S ..4 / ett/ �C.4 Z* <br /> Usid _Pa_ 0—AS 7-10- r4s i7.�r 2 r�Lj_*01' df <br /> __M_+A iL- r(/iettlGeO, /V d I/ro "A &e- COA-64—Al- <br /> I <br /> Inspection Form Included: <br /> Comments Include — <br /> uslness Rep' Signaturil Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKTCyrrClWM <br /> ec Incorrect: E X A M P L 1 Z 3 <br /> ■ White Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />