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09010040194 <br /> c Waste. Tire Survey & Inspection Report Inspection Report Number <br /> e of Caltforn6 <br /> CrN1dB1S1(N. Survey Form Page1 1 1 - 10 7 3 5 9 8 <br /> CM/MB 781(New 04!04) <br /> California Integratem <br /> d Waste Manageent Board -. <br /> Part A-Survey. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID-— _ Inspection Type (Fill one) <br /> Site Sutfix: 3 7 6 12- 131 [�Rl '®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Emil one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspecte&By Inspector it <br /> Physical Address 3 - 0 f LAyy�yq�QO.GfhYn� <br /> _ 5 <br /> Street <br /> Inspection Date <br /> I °i S 3 3 I <br /> City State ZIPCode Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> OQ m maPM m QPM <br /> Operational Status The Type. Business Role .Storage Type <br /> (Fill one or (Fill all that apply) (Fill all that appy) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> 2 <br /> ,. r_ -1 ®Active 41 Passenger: ®Generator Q Outdoor <br /> GPS Latitude W L� Q Closed Q Altered Q Q <br /> Hauler Indoor <br /> 0 Q Inactive 4&Truck <br /> Longitude _ - Q Planned ®OTR Q End-Use ®Container <br /> Business Type (Fill all that appy) <br /> New Tire Dealer ®Auto Repair Q Trucking Fleet Q Govemment QRetreader Q Dismantler Q Tire Derived Fuel i <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ®Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire.Dealer,Generator,Hauler and End-Use Facility EN'ORCEMEN1T STATUS <br /> V A WA LING AND MANIFEST M UIREMEN S <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complian 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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi for OV or <br /> Q Q 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 CIWMB 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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments f7 <br /> 1.�CA'J���iSiZ- <br /> _� <br /> irv. iry�� aILiv L M,t <br /> i- <br /> Inspection Form Included:0 <br /> Q <br /> Comments Included: <br /> -9755 __ �}lt�� <br /> Business ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON'BACK Correct:+♦ Incorrect: IEIXA M P E111-212 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator - Pink Copy.LEA - ® ■ <br />