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07312040168 <br /> = ,- Waste Tire Survey & Inspection Report inspection Report;.Number � <br /> Survey Form - Page 1 3 - 1 0 7 3 5. 1 8 <br /> C <br /> Callfomla InteIWMe 181(New 04041 grated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> - I p Inspection Type (Fill one) <br /> Site Suffix: <br /> Ske .I 3� / �l �t 31 1®Routine 0 Re-inspection 0 Referral 0 Observation <br /> TPILocal If Referral,choose referral type(Fill one) <br /> Identifier: �' ^1"p ,t �Zyy�.� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other' <br /> .J <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address UE La_-_ <br /> I 3 <br /> Street q <br /> Inspection Date <br /> S21�SCJ <br /> ', Ci(y late 1 Code Time In Time Out 1 <br /> Business Rep Title 0 AM 0 AM <br /> m'F 1 0 PM m-m ®PM <br /> - <br /> - Operational Status Tire Type Business Role Storage Type <br /> I i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> I 1 '0 0 Closed 0 Altered <br /> GPS Latitude f I I 1 0 Hauler ®Indoor <br /> _I__I_—�--I— 0 Inactive 0 Truck <br /> r r 0 <br /> Longitude I I I �� 0 Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking.Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityNFORC--EMENT STATUS__ <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, <br /> Gompllance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle / m / m <br /> 0 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred I CIWMB nforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In C-ompliance - No Violations <br /> 0 1 0 Other: § <br /> Comments fJ <br /> I' T.r���•}-q�.tlk7�—�!�C�r�.l_-LAVOiSCi—yes-uc.CoL.—INJv..�—�'�_1-4.v.[.��t._rN-O -H rcS <br /> Inspection Form Included:0 Y <br /> Comments Included:0 /` i y�bg—jSl.L3 <br /> Business Rep' ignatur Phone Number nspectors Slgnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr t: �l Incorrect: ❑E X A M P �: 1112131 <br /> ■ Whil Copy CIW Yellow Copy.Operator Pink Copy LEA ® ■ <br /> l <br />