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08206040141 <br /> or <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr State of Calilornia <br /> rCIWMB 197(New Oe/94, Survey Form - Page 1 1 4 1 0 7 9 2 7 6 <br /> CaIMomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 7plp- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: � jQ CHP Q CIWMBQ Complaint <br /> Q Educational Visit <br /> Other I <br /> Business or Facility Name. - <br /> /�� Inspected By / Inspector <br /> _ ( <br /> Physical Address o � I <br /> Street D <br /> L—�n,�(((��J G Inspectlon Date <br /> i�`/ "-� �✓ t � Time In Time Out <br /> Ci(y J Sfale I o e . <br /> Business Rep Title - 0 AM Q AM <br /> M' EI]OPM 0 P <br /> ---- -- -- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active Q Passenger i Generator 0 Outdoor <br /> O <br /> Latitude II I I Closed Altered <br /> (jPs L—J_- I.L _�� Q O Q Hauler Q Indoor <br /> _ ___111 0 Q Inactive 0 Truck <br /> Longitude - I 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 /> 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V A !HAULING ANO MA (FEST REQUIREMENTS <br /> Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q <br /> Q i O 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 <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 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 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-om Ilance - o Violations <br /> Q Q Other: § <br /> Comments <br /> 44Q /L - -e- <br /> _74 <br /> G_ <br /> No7f�, <br /> Inspection Form Included:Q <br /> Comments Included:Q — <br /> Business Rep' Ignature Phone Number :::In pedor s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK -or"Met Indo ect: E X A M P L E�2� <br /> ■ WhiteCopy:Cl M Yellow Copy:Operator Pink Copy:LEA ® ■ <br />