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09210040251 <br /> = �. Waste Tire Su ey & Inspection ReportUtIInspection Report Number <br /> State of fWMB181(Now Survey Form - Page 1 1 5 - 10 7 9 3 5 1 <br /> CIWMB 781(New 04104) <br /> californla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one). <br /> Site Suffix: 1 � O . l 1'q (9 I p2 l - 1 I® Routine Q'Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: kSQt(, �OCIiI�� �F-r i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility.Name -��/ Inspected By Inspector <br /> Am <br /> Phys cal Address t <br /> Street <br /> Inspection Date <br /> L_6_k_0C' bTn a �l5 i v <br /> City a87IS ZI Code Time In Time Out <br /> Business Rep Title 2 0 AM0 AM <br /> ru : <br /> V O ® PM � 'M <br /> ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ®Active Q Passenger ®Generator Q Outdoor <br /> PS Latitude O Q Closed Q Altered <br /> GL11___i <br /> — <br /> Q Hauler ® Indoor. <br /> Q Inactive ®Truck <br /> Longitude I O Q Q End-use Q Container <br /> Planned Q OTR <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other t 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 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violatio Q Extension <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 O 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 (Required for NOV or EX <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/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 C-ompliance - No Violations <br /> 1010 Other: § <br /> Comments \kyle Q✓t �1 13f 0.hL` <br /> putllrl� <br /> c,J Cc,'-' Y)o4e"C� <br /> Inspection Form Included: Q�iness <br /> ��p l/ �u `� c� <br /> Comments Included: Q "` `� ` 1 -6 a `- `4e-767 <br /> Rep's Si re Phone Number Inspe 3r'"Ib ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct. correct: EXAMPLE 1 2 3 <br /> White Copy CIWM Yellow Copy.Operator Pink Copy.LEA <br />