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0734840048 <br /> Waste Tire Survey & Inspection Report Inspection Report Nurri er <br /> Sta tool 181 tomla Survey Form - Page 1 1 3 - 10 7 3 4 7 6 <br /> CIWMB 181 sW M nag4) <br /> Calllomla Integrated Waate Managamant Board <br /> Part A-Surv_ey BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 5 y . Y J ® ' ®Routine Q Re-inspection Q Referral Q Observation { <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier. L Saw. N .+a � ��y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name) <br /> Inspected By Inspector <br /> r Lptr ���incq1 Grvz�� F I i , I -_ .' <br /> Physical Address A 13 19 I - i 0 I i A a��c._ <br /> Inspection Date I , / 0 ` / I'J• 1 <br /> S tL cK+vrt CA fY 7-15-- <br /> Time In Time Out <br /> Business Rep Title '0 AM I 0 AM <br /> - <br /> ®PM O PM <br /> -- OperationalStatus Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r '0 ®Active Q Passenger Q Generator Q Outdoor <br /> Latitude D Q Closed Q Altered <br /> (jP$ Q Hauler Q Indoor <br /> Q Inactive i Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS____ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ 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 /> Q Q 14 CCR§18459.1-Tire Program 10 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 1 Q Other: § <br /> Comments t�'1�7 <br /> -- 1���.Jarv« tns�a.�(-+��_—ems�S— ln.��.. uScc—!�✓LSOxf—(iL�.e���c— <br /> -/-VO fiK(---.O bSreW-id p•s'+ 0-4e_ OLA40 tq_D CaLhtMf <br /> Inspection Form Included: Q <br /> Comments -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />