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08129040763 <br /> stn, <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California <br /> Cgrated 1(New06/lle) Survey Form.- Page 1 11 6 - 1 0 7 9 4 8 4 <br /> California Integrated Waste Management Board , <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I I I I I - Inspection Type (Fill one) <br /> Site Suffix: j -3 3 L `�. C7 *'Routine p Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: I �jq h v� C�y,u �--per Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or'Facility Name Inspected By Inspector <br /> Physical Address - � lollLI�V1�I1�o�fi� I <br /> Street <br /> Inspection Date <br /> t lid; et'S 29aJ o <br /> City Slate cup Code Time MO Time OutIn Business Rep Title � I; PM 0 AM <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '' �'� <br /> Active ®Passenger ®Generator Q Outdoor <br /> i IO Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> —1---� Q Inactive Q Truck <br /> Longitude - I i ( ( I I� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility rlu �,-.ITS ATOS <br /> nvmwA,wFi%RwL,iNG AND MANIFEST REQUIREMENTS <br /> iolation <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of VQ Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Comoliance Uea fine <br /> Q Q PRC§42956-Registration/DecalVehicle <br /> Q Q 14 CCR§18459 -Responsible Entities <br /> Complying with Manifesting Requirements Date <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 EXT) <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 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 O <br /> �W+1�• ty��tsc�!-..t��,,,_ 61, "h.,-C—c.IE...��-_ �a'_�.IT�cc�_ i_c <br /> _j f s „ c� sa—tl'res c51�s�,tnf-� <br /> a- -Est^—ti— c' —►'�( ^- A.lo—�t, iu�: <br /> Inspection Form Included: Q �l <br /> Comments Included:Q � y :.-�.✓ br'' 3 <br /> LLgnature Phone Number nspe�ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I EV AIMI P I L I EG I fl-2I 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ■ <br />