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r" � <br /> ® NWaste Tire y & Inspection Rept Inspection Report Number ■ <br /> State <br /> I M8 811(New 04/04) Survey Form - Page 1 i 2 - 1 0 2 5 7 1 <br /> CalifornaInte rated Waste Management Board -._. .I <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile pl� rr�r l �a n2 rw Yr°f <br /> Inspection Detail « Yf dui <br /> y' r:r� ", ,. - s MAIM,' iEy .,yam L <br /> TPID- / � r. � r � I � I ,f � - � � Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> - iAJ <br /> Street Inspection Date [,,-)E � E <br /> + c <br /> City State ZIP Code Time In _ Time Out <br /> Business Re _ <br /> p Title 0 PM 0 PM <br /> Operational Status Tire Type Business Role StorageType <br /> Tire Count(Whole/PTE) <br /> s (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active <br /> r' 0 0 Passenger Q Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . Hauler 0 Indoor <br /> O Q Inactive 0 7-ruck <br /> Longitude — f 0 End-Use 0 Container <br /> g � f � � Planned � OTR <br /> rmRa r�".ti�mr j ,, r,fin s,.,rrr rrr„",' ,'T�G` w'raC,T�, <br /> Business Type (Fill all that apply} <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A I HAULING-AND-MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m ( m / <br /> m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O -- <br /> 0 I 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § - — --- <br /> Comments / <br /> /tom "vL,,"r.�a, � �t.rrtaf � •��i � ,.t'^ "r c' <br /> Id-11 14- 71 <br /> Inspection Form Included. 0 <br /> yWr{M <br /> 71 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X A' A Al I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />