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09210040236 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Swte of.callfomla FII - 1088428 <br /> CIWMB181(Now 04t04) Survey Form - Pagel <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h — In ection Type Fill one <br /> Site Suffix: DW I 1 ,51 S IsF7 VI I P YP ( ) <br /> lJ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local —r If Referral,choose referral type(Fill one) <br /> Identifier: J O � 1 Fig. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name WWW"� <br /> w - Inspected By Inspector <br /> Physical Address111 �e � V _� <br /> 1 /1 <br /> a%a AAAD CaKte,,,— b�- I <br /> Street J' v /v 1 F'- ^ / <br /> I ( yV� '•1� ) I Inspection Date J <br /> City I State /ZIP Ccdc Time In Time Out <br /> Business Rep Title I I ®AMI I Q AM <br /> I • � ol� 0 P ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill.all that apply) (Fill all that apply) (Fill all-that apply) <br /> Tire Counf(Whole/PTE) . f 1 • 3.• <br /> ®Active ®Passenger ®.Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude – ,i Q Planned Q 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 ® 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 F• STATUS <br /> V A HA LING A DMA IFEST REQUIREME TS Notice Of Violation 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 ( equ'e• fo O or FXl] <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 Refereed/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: §, j 1 <br /> Commentsm4f �•/1;S �{�„ �/ 1 1C�( S <br /> ire �3ra�w o� `til^� C��s�ose a�- w&,� +V:e- for s facekill,. <br /> or less Are at a �e `ase ve hk i • T�✓ode.s <br /> Vi eWO4,fGQ i0 <br /> Inspection Form Included: Q <br /> Comments Included. Q ¢�-(/�= <br /> usi a ature hone Number Inspectoes.Signa a Phone Number <br /> INSTRUCTIONS ON BACK C r!CI <br /> Irtcorre�Copy- <br /> 62081 <br /> EXaMP :LE : 123 <br /> White y. B Yellowerator Pink Copy.LEA ®. <br />