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07312040371 <br /> - Waste Tire Survey & Inspection Report Inspection Report Number <br /> cram fCalifomb Survey Form - Page 1 13 - 1 01 0 8 0 <br /> CIWMB iB1(New 04104) <br /> Lalifomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details . <br /> TPID- Inspection <br /> - / Inspection Type (Fill one) <br /> / 7 / { <br /> Site Suffix: 0 Routine Q Re-inspection- Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> IdentiFler. �Q 77 - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> J_oreFacility Name <br /> �,` 1 Inspected By Inspector <br /> / <br /> Physical Address - <br /> 3 <br /> 393 y -- <br /> Street <br /> n Q Inspection Date <br /> City State ZIP ode Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0PM m 'm 0PM <br /> i <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE' � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> QActive Q Passenger Q Generator Q Outdoor <br /> TTTI O 0 Closed Q Altered <br /> ? GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - FMQ Planned Q OTR Q End-Use Q Container <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Pati B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility BENFORCEMENT STATUS _ <br /> 101 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Exte son <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complia ce 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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days FR qu'ed for OV or F,C7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Gom liance - No V otations <br /> Q 1 Q Other: § <br /> Comments t!/QJ Z0 G���iL�c Qct G� (D aZ'V-2 /C <br /> !rl04 %"e� a-/e yY <br /> Inspection Form Included: <br /> Comments <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK . ......... IEIXIAIMIPILIEI12 3 ® S <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br />