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08151040118 <br /> ■ Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> state of California <br /> CgWMB 181egSurvey Form - Page 1 1 4 - 1 0 7 9 2 2 7 <br /> CalHomla Integrated Waste Management <br /> ment Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suff.'—'- / 0 1-7 12-1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local c /+ If Referral;choose referral type(Fill one) <br /> Identifier: G�4N 0� �N ) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L/`iZ M-9 <br /> Physical Address �ar� <br /> X204 2- <br /> Street <br /> Inspection Date <br /> �� <br /> Cify <br /> State Zlr'Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> ' 0 M 0 P <br /> — <br /> Operational Status Tire Type Business Role. Storage-Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active •Passenger 0 Generator •Outdoor <br /> —LJO Q Closed Q Altered <br /> GPS Latitude I •f- I_ _I_I J I Q Hauler Q Indoor <br /> (—_lll I j_ t _ 10 Q Inactive Q Truck <br /> Longitude — i I .I j I I I— j O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 111 <br /> Q New Tire Dealer 0 Auto Repair- Q Trucking Fleet Q Government QRetreader 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> LJ A D NIFES EQ IR E.i <br /> O OQ 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. Gompllanrx Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required Ior NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> %" :- <br /> l7rbVAdufv�4-- -Q+_�t—'c'..—BWyr ems$-�y�o rid 2od�, �(k�,Jsr�fS,s <br /> �or.nrG .•b t rd tn�_�Qc,�zp —J�i r LA-rt <br /> Inspection Form Included:Q <br /> Comments Included:Q- <br /> d'Lt 1'S <br /> Business Rep' nature Phone umber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK In'co rrect: S IM X R P1L1E1 1112131 62081 <br /> ■ White Co .CIW Yellow Copy:Operator Pink Copy.LEA ® ■ <br />