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08255040014 <br /> . Waste Tire Survey & Inspection Report inspection-Report Number . <br /> etv. <br /> Stats B California Survey Form - Page 1 I 1 -_ 1088218 _ <br /> CIWMB 181 stew 04104) <br /> CallfomW Integrated Waste Management Boats --,.__ - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i Routine Q Re-inspection O Referral O Observation <br /> Local i If Referral,choose referral type(Fill one) - <br /> Identifier: L i(Ov.AJ Tt4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> :54 eQ W <br /> (- --- --- a ; o , 1 <br /> Physical Address <br /> r– --- --- .--I j – �� � --.-- <br /> Inspection Date 119 18 2 <br /> T.L►�� cq 9 s3I _-- <br /> - Sipa Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 1 •Active Q Passenger ®Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive *Truck <br /> Longitude – O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair O Trucking Fleet O Government 0 Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> O O -- Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O - --- --- --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 O Other. § <br /> --------------------- -- <br /> Comments / <br /> _ o�,..-_'T_i�+� r_nJ�IOGG�i-a_s�—O_Y_t—jt._r's �.—%�•�Q—f'O./loL<//�W0.S N�rE�:_ <br /> 4+o Set✓� e %1 T. c �`+'/<s• - <br /> _/'vo—/ Ah'�cs r <br /> Inspection Form Included:O4B7usii <br /> J. e 209 <br /> Comments Included:Q <br /> ss Rep's S" tura Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK C e .� )ncorrect:�(a; E X A i� P 1 2 3 L E 62081 <br /> ■ White Co y CIWM Yellow Copy Operator Pink Copy LFA ® ■ <br />