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071930 50017 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> cwMB18'"°�' Survey Form - Page 1 12 1 01 3 2 6 2 <br /> 1. <br /> Snw 181 IN—ouoq <br /> Califomia meeyratad Waste Management Iaoard BLUE OR BLACK INK PEN <br /> Part A-Survey -- <br /> Business PIProfile I Inspection Details - � <br /> D Inspection Type (Fill one)- <br /> Site Suffix: 5TT7 l� 7i -- _ C� ®Routine <br /> Q Re-inspection Q Referral Q Observation <br /> Local /+ _ I If Referral,choose referral type(Fill one) <br /> Identlilli � err (r0.. C ��p _ o CHP o CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facllfty Name !!! Inspected By Inspector <br /> Physical Address 1=-_.�' - <br /> L�ar, "�ac_a{u,9J <br /> 6 X31 Cl JI <br /> Street Inspection Date <br /> Time In Time Out <br /> t - - tate t ode 7� ( �� r� �—lIAM <br /> Business Rep Title I I I:I O PM I I I O PM <br /> Il0—peralltio—nal�Status Tire Type BuslnessRoleStor—aJgeType <br /> (Fill one only) (Fill all that aPPIY) (Fill ail that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3_i�0 <br /> 40 Active Passenger Q Generator (8 Outdoor <br /> ;0 Q Closed Q Aitered <br /> GPS Latitude I ®Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude - _ Q Planned ` Q OTR <br /> Business Type (Fitt all that apply) --- 1 — - <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 I <br /> Q Service Station —0 Hauler Q Agriculture Q Shredder Q Other �— _ — i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS ---111 <br /> V A ,HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q o PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O o PRC§42953-Contracts with Registered Waste Tire Haulers Compliance Deadline <br /> Q o PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§16459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459 3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> o ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred f CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> o Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance • No Violations <br /> o Q !Other § — <br /> Comments <br /> Ins coon Forth included:QI v 1//� �du, <br /> ` �-, --fig Z9�6 <br /> is Included: ���o® �. SI na ure Phone Number <br /> slness ep s Signature Phone Number _4_ <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: a� 9 EIXIAIM PILIE1 Il 2 3 ® ■ <br /> White Copy CIWMB Yo.iow Copy Operator Pink Copy:LEA <br />