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" 09�. 960404�6 <br /> Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> StateB181( ow I1 - 1108498 <br /> callfornla Integrated WWaste Managern t Board Survey Form - Pag e 1 <br /> 'art A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + I'''!�� Inspection Type (Fill one) <br /> Site Suffix: �L I I I Jg O I I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I ` ---I�L�"' If Referral,choose referral type(Fill one) <br /> Identifier: , (� — L,)'Iy, �� , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f Inspected By Inspector <br /> Lysl ddr55 I�Le�-�Cwt/_�c/ t,C{,t/IYIJ I� I I nl?dYl� jls'lJ� <br /> Phtt <br /> LI_39GO- t_Anfl ►.V--,—A- cN)- I - - <br /> Street <br /> Inspection DateLL. I{ <br /> —" 0� State ZIP Code Time In Time Out <br /> Business Rep Title O AM I �^ O AM <br /> 10PM _ I ' I 1 D2 oPM <br /> Sqr <br /> —10rnr_>7 N —Loy-v4--",a —' ��Y ` Pcxf s 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(Whole/PTE):,'50 <br /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> _0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ®OTR 0 End-Use 0 Container <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 ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs Within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 <br /> ® In Compliance - No Violations <br /> 0 0 Other: <br /> Comments oy tuy 7s, \�I, <br /> r �b (.1Z��c,�l�� � IN L.��CZr�C)y��✓—� <br /> Inspection Form Included: <br /> Comments Included, <br /> *Vtsfiwss Rp's Signature 'Phojnee Number Nlns c for's SI �r14urePhone Number <br /> I •� �C V +f II I I l I j I 11 62081 <br /> INSTRUCTIONS ON BACK orrec : ncorrect: X AMP L 1 2 3 <br /> White opy: Yellow Copy.Operator Pink Copy:LEA <br />