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08038040304 <br /> €; <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWM8"'(New 0404) Survey Form - Page-1 1 8 - 10 7 9 4 2 9 <br /> "Ifomla InWgmtad Waste Management eoaM _ BLUE OR BLACK INK PEN - <br /> Part A-Survey -- <br /> Business Profile Inspection Details <br /> TPID. Inspection Type (Fill one) <br /> Site Suffix: / y 4 7 u S- Q 2 I 0 Routine 0 Re-Inspection . 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: 0. I ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> ty Name <br /> Business or Facili0 u v ' Inspected By Inspector <br /> Physical A <br /> !—_l i v►_ur_�—�_r✓c�tc /;z S G - L—/t vYl_un ta�F��aul`+ <br /> d�dfres9 <br /> I Street /�O�O Y S. �c��Y��/• 1 <br /> o v Inspection Date D / <br /> I <br /> City State ZIP o/— / State J Time In Time Out <br /> Business Rep Title m'm 0 Am 0 AM <br /> ®PM Eil m ®M <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE � � I I ��/1 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / i 1 0Active ®Passenger 0 Generator ®Outdoor <br /> ' I O Q Closed 0 Altered <br /> GPS Latitude 1 I —I,L 'I— I 0 Hauler 0 Indoor <br /> lL O 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 <br /> Part B-Inspection of Waste.Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENTS ATUS <br /> V A HA LING ANDAN <br /> MIFEST - UIREMENTS <br /> 0 O 0 Notice Of Violatio 0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days fired for OV or DCT) <br /> 0 - ---- --........- <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred 1 CIWMB Enforcement <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 1 ompliance - No Violations <br /> 0 0 Other: § <br /> Comments n _L <br /> KOWft'v�.t—j.N 5�-[.s4't`c� � T�.l� ��-�'-1=. •-•Jx-•(rvrd- to=ice--te2�-rrrt t1o✓� <br /> �C (s <br /> �pw_sc c�.tn.c <br /> _j ��F!/_-p'yt���.'2S_fJ_r'GJfCd—�—�i���- <br /> Inspection Form Included:0 <br /> Comments <br /> Business Rep's Signature Phone Number In ectoes Signature Phone Number <br /> —- - - - -- <br /> . INSTRUCTIONS ON BACK Lorre• I o e• . X A M P L � 1 2 3 6208181 . <br /> While Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />