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092SS04064S <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfornla. <br /> LE CFWMB Waste <br /> Survey Form - Page 1 I 1 - 1086981 <br /> California Integrated Waste Management Board <br /> Fart A- Survev -BLUE___ OR BLACK INK PEN <br /> Business Profile t Inspection Details <br /> TPID- I I I Inspection Type (Fill one) <br /> Site Suffix: 3] Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V 'vTN� <br /> Inspected By Inspector <br /> Past. SSeir 6 ro s <br /> Physical Address <br /> I 2.00 �• (�;��� I <br /> Street pe I <br /> Inspection Date <br /> l�X�t ! I 01 <br /> City Mate ZIP Code Time In Time Out <br /> Business Rep �^'- Title I O : I t i t� ®AM IAM <br /> 0 PM ' I Q PM <br /> --- —- - -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill:all that apply) <br /> 0 Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude, Q Hauler Q Indoor <br /> __O Q Inactive ®Truck <br /> Longitude - • I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RENEGRIEMMENi STATUS <br /> mLV,m=AMHI AU.LING,AND,MANIF.ESiTi.REQUIREMENUT- 1 °i 1 lil 1 ° 1 <br /> Q Notice Uf Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 1 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 Date m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB IT] <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orX7) <br /> Q O 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/C-IWMB 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 C-ompliance - No Violations <br /> Q Q Other: §, 1n c���{,q�, �(� ._f{- / <br /> Comments gei,(f Ka l•k.Spe t.V r� '"'."e� 'VY �1 nAA� ' F-a 6 has LQ k <br /> t _ i . or -t t1�e, vice oo _ 4:1T <br /> Y>�Cv � v i - No U -oLA-vh-.s <br /> f <br /> Comments Incl <br /> Inspection Form Included: Q <br /> e is I 1 ( <br /> uded. Q L <br /> mess R Sig ature Phone Number Inspectors Signat Phone Number <br /> INSTRUCTIONS ON BACK Corr bit- I correct• jEjXIA�MjPfL E1 I.112I3 62081 <br /> White Copy: IW M Yellow Copy.Operator Pink Copy:LEA <br />