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09308050022 <br /> Waste Tire Survey & Inspection Report . Inspection.ReportNumber <br /> State of California <br /> CIWMB 181(New04104) Surve Form - Page' 1 I1 - 1127585 <br /> California Integrated Waste Management Board J `�' ___ <br /> Part A-Survey BLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details <br /> TPID. � � - 1 n � 1TS-1 <br /> o Inspection Type (Fi11 one) <br /> Site Suffix: I /J - Nil Routine Reins ection Referral .� � P � � 0 Observation <br /> Local �- J�A_J <br /> If Referral,choose referral type(Fill one) <br /> Identifier. . VCjL- , r, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> Y Inspector <br /> M P <br /> Physical Address <br /> ;„/ Inspection Date Q 19 4 / .01 <br /> rty State 21P Code Time In _ rime Out _ <br /> Business Rep Title AM I r AM <br /> �►, 1 4 J OPM <br /> O PM <br /> -0 kA -- - © �- -- - <br /> Operational Status --Tire Type • Business Role Storage Type. <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fin all that apply) <br /> oActive 0 Passenger e Generator 0 Outdoor <br /> -- - - O 0 Closed 0 Altered Nf,Q <br /> GPS Latitude % I I I ` 0 Hauler 0 Indoor <br /> —'-1 • ---'- L- - -- --' 0 Inactive 0 Truck <br /> Longitude <br /> 0 Planned 0 OTR O.End-Use OContainer. <br /> Business Type (Fill all that apply) . <br /> .0 New Tire Dealer. 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader .0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other 111, f.,.1 �w� 1f � <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and-End-Use Facility I, ENFORCEME`N�ITSTAT,.U$ �z <• <br /> N ,, <br /> Vim; AAg HAULING�AND MANIFEST REQUIEMEN_TS_x ; ;t O Nati 1%i I ti n Ezt ' ' <br /> o ce,Oft o a,o 4, 8„ens on <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires c , <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. � <br /> 0 0 § 9 Coinpllance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle " 6 <br /> 14 CCR 18459 -Res Responsible Entities Complyingwith Manifesting Requirements f <br /> 0 0 § P 9 q Date 7, <br /> M:Y0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMBY �,. <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requrred forNOV;orDCTJ <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years �"` 'gyp yyy,, <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers (Q Referred/CIWMBEnfortfine it <br /> }' 4 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators +` '� 4,. <br /> ��InCompllanceot No" Violatlon <br /> 0 1 0 Other: § <br /> Comments �\ \�. •t�-1-�v iV� --.y. �a1t�.l—-- � r <br /> Inspection Form Included: 0 Ot 0 -P) <br /> Comments Included:' __ <br /> Business s g ure Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrec +Incorrect: E X a M P L E 1 Z 3 62081 <br /> White opy. Yellow Copy:Operator Pink Copy:LEA <br />