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08234040.306 <br /> Li€i, Waste Tire Survey & Inspection Report Inspection Report Numberto <br /> ■ <br /> 1t; SIWMBt'oCalH rola SurveyForm - Page 1 Il 1088154 . <br /> CIWMB 191(Now 04/O4( <br /> California Integrated Waste Management Board - <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- q - Inspection Type (Fill one) <br /> Site Suffix: I / 9 <br /> 013 ` O / •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. CrOt1N_7t Q CIWMB QCom taint QEducational Visit <br /> Q Other <br /> Business or Facility Name ✓ Inspected By Inspector <br /> �.aq ks k1Esr f�.a,eL — <br /> Ph l al Address <br /> 63900 ,y4,2,J_A^j l� I �Trrtr <br /> Street <br /> Inspection Date <br /> 5 330 � <br /> "dL — C� State Zl�ode Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ' Q PM �'� 0 PM <br /> TOmmr./—r!OrG�O__.�f!•__paiirs_8 Sae- <br /> � -' I 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(Wholb/PTE) <br /> .3 0 Active Q Passenger 0 Generator •Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> — -_ -- ---- Q Inactive Q Truck <br /> Longitude _ I I 1 Q End-Use Q Container <br /> 9 1 - L I.I Q Planned 0 OTR <br /> Business Type (Fill all that apply) <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 I� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other (MO(pri.7t�G�C .�A)±SISriVi'L_G� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility Lr.r�+tstrircrWi STATUS <br /> VjA�IHAUL•INGjAND1MANIFESiTilREQUIREIVIENTiS (0 mum @q Violatbn ( 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 <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 FXf) <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/GIWMB 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 /> '�7-'�)f.-- — -/ !•� —� a r_a.9_: <br /> .N._.D_ Al n ✓ b �S a, a- <br /> f <br /> Inspection Form Included:Q C-26ef <br /> Comments Included: F04M-� )�+■�`��- 4�® CW <br /> Business eb' �Signlre Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrecte Incorrect: I I I 1 62081 <br /> �,, I�IxIa � p .L E i z s <br /> ■ White py.Cl Yellow Copy Operator Pink Copy LFA ■ <br /> I _ <br />