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07340040333 ■ <br /> Waste Tire Survey.& Inspection Report. Inspection Report Number <br /> Stale of California 'Survey Form - Page 1 I 1 6_ - 10 7 3 3 3 9 <br /> CIWMB/Bt(Naw"U) <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 � - O � Inspection Type'.(Fill one) <br /> Site Suffix: J 11 I ®Routine Q Re-inspection Q Referral Q Observation <br /> Loral �^ If Referral,choose referral type(Fill one) <br /> Identifier: 14 Q CHP Q CIWMB . Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I E� I� <br /> Phys I ress 3 -/ - , [ I o I T,24v�1�y � I <br /> I if 39 Qo 14a+ :H R a O <br /> IStreet L�o / Of Q5330 I Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title _1 O AM 0 AM <br /> Tomwi LO edO r m:F1 m FFI t7PM <br /> '------�" �� arts_�_Str�r_C_Z <br /> Operational Status TireType 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 I I I (V15! <br /> ®Active 0 Passenger. ®Generator ®Outdoor <br /> m O Q Closed Q Altered <br /> GPS Latitude � I � ' �I I I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> O <br /> Longitude - J I - I I� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply). 111 J <br /> Q 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFU`R^/�ME'N_jTST TUS �J <br /> �A�;iHAli hiNGGANDIMANI&EREQUIREMENTS <br /> Notice Y a on 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 Deadll e <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities 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 (Re d/or O or <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 Refe d!CIWMB E fo ce e <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 mpliance - No V11 tatlons <br /> Q Q Other: §,, ��^^ ��j ,.'t /� <br /> Comments V✓t/ru � r`�I s5 �� i/F kiGW-til �; o GL Qn�.�rri!S wQS <br /> '711 E_ — }eve_S-toct� 6P1D*1100575) wh�i It �- C/or ,�a Ti'✓e - <br /> G1A-x_<ayj&A ' az ---No._Ataa&sf forms _ _ <br /> A1W <br /> -- — 3 �� N ` <br /> ��-}- r�vlS ►' o y�oL.-- S no - <br /> Inspection Form Included:Q a/nU <br /> Comments Included: - - qw-0,Y20 <br /> Q si R 's Signature Rhone.Number Insp f'sl�ignatura�.. Phone Number . <br /> • � I <br /> INSTRUCTIONS ON BACK Correct: IncorreI E }( <br /> ct: A(MIl•I P E1 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA <br /> I- <br />