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09210040510 <br /> ■ tt:t Waste Tire Survey & Inspection Report P p <br /> _ ::�� - Inspection Report Number <br /> State rr crWM 181(Nrnla Survey Form Page 1 �I1 1108443 —J <br /> CIWMB 187(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: �I� IL� a I I I © I I ® Routine Q Re-inspection Q Referral Q Observation <br /> IdenLocal � _1� H Referral,choose referral type mp one) <br /> Identifier: (� CHP CIWMB Q Other <br /> •�,.� � Q Q Q Complaint �Q Educational Visit <br /> Bu ' eess or Facility a Inspected By Inspector <br /> t �IL► /5 �1� � �QVL� I _ n <br /> Physical Address , <br /> Oil L_'.JCI_1 ev <br /> ,•- X53 �J .fit-1 `�`�W---��'111��I <br /> Street <br /> ( , j� Inspection Date <br /> L W1� Ch {5gAo <br /> City State ZIP Coo'e Time In Time Out _--_ <br /> Business Rep Title O AMO AM <br /> _4� ' L— PM1'5 PM <br /> --- Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) u (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r 1 Q Active ® Passenger Ir Generator f Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> L - `_' •` - - - - Q Inactive Q Truck <br /> — ---- -- - — .O <br /> Longitude - ' I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer •Auto Body Q Car Dealer Q Collection Q Crumb Rubber- <br /> p Service Station p Hauler p Agriculture p Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEME VT STATUS <br /> V A RULING A D MANIFEST REQUIREMENTS <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. C-om Iian a Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <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 EX7) <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/C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 1n Compliance - No Violations <br /> 10 1 Q 1 Other: § ---- ---------- <br /> t <br /> Comments <br /> (AACQJ'tn- <br /> VIA <br /> _ ��,- � _ _ S � 0.s- �,, - , ►��.h � <br /> Inspection Form Included: <br /> Comments Included: <br /> tsin ss Rep's Signature Phone Number Insp or's.Signature Phone Number <br /> INSTRUCTIONS ON BACK C5rrec Incorrect: EXAMPLE 1 Z 3 62081 <br /> White Co Yellow Copy.Operator Pink Copy.LEA <br />