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07312040471 <br /> rrr. <br /> Waste Tire Survey & Inspection Report Anspection Report Number - <br /> �r Stab of C.Iftmla <br /> CIwMs181.(Ne-0004) Survey Form - Page 11 6 - 10 7 3 5 4 5 <br /> "If—toW.gr tad Wind.Manag....t Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1a L Inspection Type (Fill one) <br /> Site Suffix: / "J Q I / y ®Routine Q Re-inspection Q Referral .Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��, #,� Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name U Inspected By Inspector <br /> I Nor Ca, P X 1lij�l <br /> Physical Address L�77�tL41 l7 <br /> otX�•r1eM� I <br /> IFtrccl vc I <br /> Street <br /> Inspection Date 1 <br /> I i uc.�+tar. C.A 9S T T� <br /> City State�IF' ode Time In Time Out <br /> Business Rep Title m'm®0 AM 0 Am <br /> M m'm ®PM <br /> I Operational Status Tire Type Business Role Storage Type - <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> l 0 Q Closed Q Altered <br /> GPS Latitude W,I I Q Hauler Q Indoor <br /> - —I ...'iO Q Inactive Q Truck <br /> Longitude — L- Q Planned ®OTR Q End-Use Q Container 1 <br /> Business Type (Fill all that apply) I <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 ®Other LS <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCE EN1T STATu_S <br /> Nmffil%fflfflfilNU MA IfE TRE UIRE EN S <br /> Q Notice Of Violation Q 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle r <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m ` ED <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 EJCT) <br /> 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 10 1 Other: § <br /> Comments <br /> �Grl�+�-'►'1^_c._iyJS�yGe,�E��'1V� O'y1�hS—C16� KLA-1SJCA'C,�—�J�K6�1_S—W+(.SO'>n <br /> VV <br /> Inspection Form Included:0 <br /> Comments Included:QN Slg8—0 6 2 3 <br /> Business Rep' natu e I Phone Number Inspector's SIg ature Phone Number <br /> INSTRUCTIONS ON BACK o reef: or c EXAMPLE111213162081 <br /> ■ Whit copy.CM!M Yellow Copy Operator Pink Copy LEA ® ■ <br />