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08157040103 <br /> = r Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r� ote of CalNornla <br /> CraIWMB 181(N-eaorl Survey Form Page 1 LI 2 - 10 7 3 4 4 2 <br /> CalHomla Integrated W..t•Man-g-t Bab <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D <br /> [�5D2 Q Routine Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CA-'j J 6.4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � r <br /> Physical Addre [�al - [ail La�j:I P41MrAJ __j <br /> I 9Do .4 444.,p454_,Qat <br /> Street <br /> Inspection Date <br /> 6211 <br /> City C_A Stafe ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> T �,GrdF.L Q PM LLI Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> kss (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE), <br /> r 0 Active Q Passenger !Generator Q Outdoor <br /> r -I-- <br /> Latitude I ( I •O Q Closed p Altered <br /> GPS _I I Q Hauler Indoor <br /> -_ —O Q Inactive Truck <br /> 1 I <br /> Longitude - I I -I•I` 1 I —�I- Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J ll <br /> Q New Tire Dealer Q Auto Repair fo 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 1ENFi1EfR0EMENi1jfSiATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Gompltance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mm / 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 {Requi ed for NOV or DC7) <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 1 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 Compliance No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> �(a�r�.- <br /> —�!� �I4.�.��►re.7-r�cl�P�t_.—N�(firs�A--r'7_O^)3 0.�cA�!_Cf,PJ=IS _� ..__. <br /> Inspection Form Included:Q / <br /> Comments Included:Q -- - - - --- <br /> Bu Irle 's Sign r Phone Number Inspector's Signature Phone Number . <br /> INSTRUCTIONS ON CK Cd rrect. Incorrect: IEX R M P L E 1 2131 62081 <br /> ■ White Cop CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />