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08129040066 <br /> eee. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stereo/Calfamla Survey Form - Page 1 1 2 - 1 Q 7 9 4 8 Q { <br /> CNYMated tat Waste(New eHManaggA <br /> ement 9ear <br /> Cali/omla Integrad <br /> 'art A-SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 15712 I D 1- -1 - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> j Identifier: Ls.C , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L—M , Tnt C Ad—'o 'TV ITi] - <br /> Physical Address ress <br /> Street <br /> Inspection Date <br /> City State Zlp Code Time In O PM Time Out <br /> O PM <br /> Business Rep Title 0 AM 0 AM <br /> �"W <br /> ,I� �'� m'W <br /> ';i.S-A-)O - -- <br /> Operational Status Tire Type Business Role Storage Type .. <br /> Tire Count(Whole/PTE) 1 { 1 I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator ®Outdoor <br /> U 0 Closed 0 Altered <br /> PS Latitude I I 4 I I I 0 Hauler 0 Indoor <br /> G <br /> 0 Inactive ®Truck <br /> �O <br /> Longitude I 0 Planned 0 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 0 Other I <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 Q 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 Data m / 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 EXT) <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 /> I <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 P <br /> ®In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> .:�,+�1LtS_p_�¢.�I�-o✓ti---OYL`�'f�+iS_G(,at�L� �4-G�r` l�<-�/�r�tq_v�G� <br /> rs Ltc<a!—.Z 1=��!2s ..r fin, pe f <br /> _tLL[SC�aLd %n fit�,puf}• / y�_O�iE1�u�2 c—/��ch—l�laScd&J iPlD <br /> ee�se trod Lf/St/ox X 52-7-0 5'y- . /V o Vro f_ kfi;rl tl <br /> Inspection Form Included:0 <br /> Comments Included: ` r�-� <br /> 0 Bu Sigt�atw phone Number -lfi sparlor's S��ignature Phone Number <br /> INSTRUCTIONS ON BACK <br /> ��jh Incorrect: ( l �IIEIIxIaIIMIPILIE[ 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />