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08129050047 <br /> Waste Tire Survey 8t: Inspection Report Inspection Report Number ■ <br /> State of Califomla <br /> CrWMB 181(N..o4ltW) - Survey Form — Page 1 1 3 - 1 0 7 2 8 3 3 <br /> '+!~ Califomla Integrated Waste Management eaard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (�J Inspection Type (Fill one) --- <br /> Site Suffix: I3' 10 r l - I I �'I O / ®Routine 0 Re-inspection . O Referral O Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier: Jo— _ / O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name �7�1 Inspected By - Inspector <br /> I a� e�� R.CO_t/Z!l <br /> Physical Addr <br /> L300-9 S. /�It2c iLtr Jr <br /> Street '75-37'? <br /> � � /'1Inspection <br /> City 1\/H' Stafe ZI Code Time In Time Out <br /> Business Rep Title /� 0 AM Q AM <br /> f°\�,+'� �kr Nu�w�t�e 1�� F <br /> -m O PM m'm O PM <br /> Operational Status Tire 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 /> 1 V O ®Active ®Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude I I Q Hauler Q Indoor <br /> �__-I i__I- I--_I-II O Inactive ®Truck . <br /> Longitude -: I 0 Planned OTR ®End-Use ®Container <br /> Business Type (Fill all that apply) 111 LL <br /> O New Tire Dealer Q Auto Repair Trucking Fleet Q Govemment O Retreader O Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer ®Collection O Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder ®Other � ✓"C�!�%'`^ ���U�1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler•and End-Use Facility ENFORCEMENT STATUS <br /> V I A !HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation 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 Date m / m / m <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q1 Other: § <br /> comments P t <br /> Col1e s Yes �rccv)s�e.� S- erl and S bro _ _ Scf'e b <br /> iom ms's _�t'te. TI . ).-2 )` $ -N). G� <br /> r�s� ��h,i�,4 ' <br /> Inspection orm Included: /yT�� <br /> Comments Included:® c `J a/ QK — <br /> Business Rep's Signature Phone Number Inspec s gignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X&) .V E X A M P L E 11[2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® . <br />