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08129041119 <br /> Waste Tire Survey & Inspection Report Anspection Report Number <br /> ta <br /> (N <br /> 0 Ste"r"_""r"_"" Survey Form - Page 1 1 5 - 10 10 8 6 0 <br /> CIWMBed 181Waste ew ONoe) <br /> Callromia IntegratManagement Bord <br /> a <br /> Part A•Survey BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type (Fill one) { <br /> Site Suffix: !r 3 3 g tD ®Routine Q Re-inspection Q Referral Q 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 Inspected By Inspector <br /> Physical Address - <br /> [�W] L grA'l"e-D <br /> 3,2423 /-rou�f Z <br /> Street <br /> 619 <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> �T� UL. g, m ' m0PM m 'm 0PM <br /> t7l <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire D <br /> _ ®Active ®Passenger •Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ FT-f-1-1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 41 New Tire Dealer Q Auto Repair Q Trucking.Fleel 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 STATUS <br /> V A HAULING AN110"A-11 FEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q. Q 14.CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ae."Q.� /'`�� �.�.tir %/`�' � /e�.s✓e ov�v�Y�i•e�. r'/.�� ,j' <br /> Inspection Form Included:Q 0 9 <br /> Comments Included:Q�- - 20'�73 a7Ty � Q� "� �wg^�3 <br /> Business Rep's Signat a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK LA IEIXIAIMIP L 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■. <br />