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08052040059 <br /> eee. <br /> Waste Tire Survey & Inspection Report Inspection Report Number: : <br /> State e 181California Survey Form - Page 1 l 8.- 1 01--Q'8 3 9 <br /> CIWMB 167(New.f14/04) <br /> cattfomta tntagrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: / ;(�1,,2_1 O 171 7 q I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �a 4+ti�r <br /> GG Q•CHP QCIWMB QCom Taint <br /> Q Educational Visit Q Other <br /> Business or Facility Name ^ Inspected By� Inspector <br /> Physical ddresIs / / I <br /> 1 707 7/f, <br /> Street <br /> � _ 1 I Inspection Date <br /> City (State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> /,/r�/� m'm O PM m'm O PM <br /> Operational Status Tire Type Business Role Storage.Type <br /> Tire Count(Whole/PTE) (Fill one only). .(Fill all that apply) (Fill all that apply) (Fill allthatapply) <br /> 1111 r r "J 40Active Q Passenger -Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> O Q Inactive A Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> -I- LL 1 <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 L I <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility IIIENFORCEMENT SITATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1'-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX77 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 1 Q 1 Other: § <br /> Comments �� <br /> f'�_4re-r / /✓�� I�uccodt GlJa t /� C•,i/,6LL r J, !�y°�✓�o� <br /> Inspection Form Included:Q ��ti T•!•/�r�/�-c {/��03 <br /> Comments Included:Q — <br /> Bust ss Rep's Signature. Phone Number Inspector s Signature Phone Number <br /> 3 62061 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: e X A M P L E. 1 2 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />