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09280050004 <br /> Waste- Tire Survey & Inspection Report Inspection Report Number <br /> r� State of California <br /> CIWMB181(New04104) : Survey Form -- Pagel I1- - 1086920 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details :Y <br /> TPID- 1 115 <br /> O � � � � _ O ( Inspection Type (Fill one) <br /> Site Suffix: ` * Routine 0 Reinspection 0 Referral 0 Observation <br /> Local c� H Referral,choose referral type(Fill one) <br /> Identifier: SiQ u , 1 �i (� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I qPhysical Address <br /> Street� 3�" <br /> Sitto-&-A-0 <br /> �^y_ �� Inspection Date �I / 4�7 <br /> ( v___. Q(�- ` ��Zlp - Time In Time Out <br /> City State ZIP CO.-ye <br /> Business Rep Title i AM O AM <br /> r. ; c a X51 [7eAPM � 0►PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> 3 Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed. 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> t7 0 Inactive 0 Truck <br /> Longitude - , ; i 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Ce, <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 ® Other tn( <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENO CEMENT STATUS �"`yi.j j� <br /> V A HAULING AND MANI I iEST REQUIREMENTS <br /> la <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires ® Notice of Vion 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. -ompliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 Req iced for NOV or EXT) <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 0 Referred CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 1 0 1 Other. § <br /> ,,, <br /> `` �- � 1 �.} <br /> Comments _aam-1 o��.d.'_0–L,��S C'Q'a— Qk n — <br /> ol-W, �) T N - _j V_. <br /> ` Ql,.s_�-155 - __ �u�_ o m, Q ROW <br /> P �u� cern. <br /> Ins ection Form Included: . _ o/ <br /> Comments Included: IS �yv �(J W(/ 60q)%L✓=•o- <br /> Business Rep's S' ature Phone Number Inspectors Ignature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK E WAIMIPILIE1 111213] <br /> . While CopkzW Yellow Copy Operator Pink Copy LEA <br /> I <br />