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09024040132 <br /> E Waste Tire Survey & Inspection Report Inspection Report Number <br /> ern_ <br /> r[ CFWM 181(New ' SUrVey,Form - Page 1 -I 4 - 1 0 7 9 4 17 <br /> ClwMB i81 t(New 04!04) <br /> Califomla Integrated Waste Marugement Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Tite - tZ_T -1 17 17 /t - O I Inspection Type (Fill one) . <br /> Site -fFlx: J OL" 40 <br /> Routine. Q Re-inspection Q Referral Q Observation <br /> Local <br /> Identifier: If Referral,choose referral <br /> n`' \ 1 type(Fill one) :. <br /> V O kiN Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> - -- - - <br /> Business or Facility Name <br /> Inspected B <br /> SS -n�, .Y/ P Y �r Inspector' <br /> Physical AddressI,Ire. ( _— I ✓ 1. - l V <br /> Street _ _ m <br /> Inspection Date <br /> City Iy J�taJte ZIP Code Time In Time Out rJ <br /> Business Rep Title 0 AM 0 AM <br /> �` 1 rC: vrneG m m 0 PM m m 0 PM <br /> I I I Operational Status Tire Type - Business Role Storage Type .. <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)! <br /> 40 Active 4&Passenger ®Generator Q Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> Hauler indoor <br /> O <br /> - �'-- --i� Q Inactive Truck <br /> ® Q <br /> Longitude I I I Q Planned ®OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 <br /> I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q ! Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q I Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> m <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 (Required for NOV or EXT) <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 I CIWMB Enforcement, <br /> Q 0 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 1 Other: § <br /> Comments ` <br /> _& _- Ms u� �JQ1tJ ititvolcss ` `a ` <br /> .._ 07-030 i3 R'3"71?A9 /i/� 9/r <br /> Inspection Form Included:Q �[ �e2o°1 03$`353(p y <br /> Comments Included:Q __ <br /> _ Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> Correct:* Incorrect: 62081 <br /> INSTRUCTIONS ON BACK <br /> � ■ �� � � X.A � Pr�.'E 1 .23 <br /> White Copy.CIWMB. Yellow Copy:Operator Pink Copy:LEA ® ■ <br />