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08206O4Ot44 <br /> «<� Waste Tire Survey & Inspection Report Inspection Report Number <br /> s"'* 'c""""' <br /> Surve Form - Pa e 1 1 8 - 10 7 9 2 7 1 <br /> CIWMBc (Now 06/B4)- Y ('� <br /> "(forma Integrated Waste Management Boartl `�• <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /� Q D Inspection Type (Fill one) <br /> site Suffix: n 9 �� `✓ _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ss.^( tJ4gq ,'AJ 6V^J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name () Inspected By Inspector <br /> Physical Address <br /> 408SS <br /> . Street �7 Inspection Date © •s 2 S / O 8 <br /> �3D I <br /> city SfafeZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> �cl�,2 <br /> Ij- O PMLLI O PM <br /> — - <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r /- •Active Q Passenger •Generator Q Outdoor <br /> fI 0 Q Closed Q Altered <br /> GPS Latitude —I�•I I _� Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - ] Q Planned *OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer .Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility ENFORCEMENT STATUS _ <br /> V A HA LING AND MAN FEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q Q Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Re wired 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 f CIWMB Enforcement <br /> Q Q 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 C-ompliance - No Violations <br /> Q 1 Q 1Other: § <br /> Comments 'NG /NStOQyJ<iay� B'St /K.�••e G7 v Wcy�=,at]p • <br /> _ � -_G ,��,o °77 _s Cly. i�,. ►- t_'s .-� ,fir. <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Bu ' ess Rep's Sig lure Phone Number Inspector's Signature Phone WuJiber <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre t: 11 C IEIXIAIMIPTLIEI 1 2 3 <br /> . - , Whit Copy.Cl M Yellow Copy:Operator Pink Copy LEA ® ■ <br />