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08055040040 <br /> Waste Tire Survey & Inspection Report . inspection Report Number <br /> CIWMB 181 spar.or cailro�,o <br /> Callfornla In eB afeE WastosMa, amonr award Survey Form - Page 1 1 7 - 10 7 3 4 1 4 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPe - - O Inspection Type (Fill one) <br /> Site Suffix: ®Routine O Re-inspection O Referral Q Observation <br /> Local — <br /> ` If Referral,choose referral type(Fill one) <br /> ! <br /> Identifier: / (� - <br /> lit.t.Vl �� C�"Z(,L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Z 1ACkVLJ'VL .-- - H�,c{a,a►��/ enc. I <br /> Physical Address <br /> I Po 6oX 1 87 - Ac, Db-rA <br /> Street <br /> I �S13n �� I 6�f,}, ���O � Inspection Date <br /> City tale ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �Ua►'bara ,_�S'e e �#a <br /> MOPM W m O PM <br /> -- _ Operational Status Tire Type Business Role. Storage Type <br /> l t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> I ®Active ®Passenger ®.Generator ®Outdoor <br /> GPS Latitude _ L I I L---��0 0 Closed Q Altered O O <br /> _1____1 Hauler Indoor <br /> r I 1 0 0 Inactive ®Truck <br /> Longitude - �IA]. L- I = Q Planned ®OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler ®Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O 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 /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 for NOV or EXT) <br /> Q 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 /> Q 1 O Other: § <br /> �,, .�;G� <br /> Comments Ww_ ANU __ was t. <br /> `rho dtS EPT tmn.F _ <br /> .7fI!_I'YLS{��v �u �' V'.2.1IZ_?._(�t1.k� ►'►'1��� ,J�d r M S O'h <br /> �C4119, <br /> IIID 5 n o�t�(, <br /> Inspection Form I cluded:O1 Yltx <br /> _ `7b��-f <br /> Comments Included:Q <br /> L/09 0 <br /> Business Rep's Signature Phone Number Inspector's gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X& X A M P L 1 2 3 62081 <br /> . - White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />