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8227040120 <br /> Waste Tire Survey & Inspection RepoA Inspection Report Number ■ <br /> araho181jgmle Survey Form - Page 1 I1 - 1088388 <br /> CIWMB 191(New nags y g <br /> C.Ilfomla IMeenWd Waste Management Bosh �a7 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I I� O ' Inspection Type(Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I 64%.A To Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> fi�4 <br /> Physical <br /> Add�esa VG� ' 3 ! — [IE <br /> 3A CcY I — <br /> Street <br /> ���N � 95a`�� Inspection Date <br /> C tl Y State ZI CodQ Time In Time Out <br /> Business Rep Title m 0 AM F O AM <br /> �y I:E7 �_�' OPM <br /> p�s --- - -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one my) (Fin all that apply) (Fill all that appy) (Fill all that appy) <br /> Active 4k Passenger ®Generator ®Outdoor <br /> Latitude .I O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> I Q ContainerQ Planned Q OTR Q End-Use <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 ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§1B459 -Responsible Entities Complying with Manifesting Requirements Date m/m / 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 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 10 1 Other: § 1 <br /> Comments cH,-/j L e AS - C_Q� 40/-4 APL A ��" 1_ , <br /> S Wkw �- LAI- �-e Wfz cf�s-oSa _ EDT ��1,s <br /> ✓I elk.e—d ee kJ a 1/io Iafl�671S. <br /> Inspection Form Included:Q /� n iq(L_n�_ � ��r J�O� �� � `Q� Z• <br /> Comments Included: <br /> Q <br /> Business Rep's Signaturik Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect:X(J� JAIMIPME1 <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® . <br />