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Jf3� 1�4G424 <br /> S Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr <br /> State of 181(Ne.CaliforniSurvey Form - Page 1 1 5 - 1 0 7 3 5 6 0 <br /> CIWMB 191(New 04!04) <br /> Califomla Integrated Waste Management Board <br /> Part A=Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> s ���� / Inspection Type (Fill one) <br /> sit. <br /> Site Suffix: 11 I 13 1 <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ��„,y� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ju <br /> Business or Facility Name - —4 Inspected By Inspector <br /> - TL �1 <br /> Physical Address- � L <br /> Street <br /> Inspection Date <br /> L <br /> A- 953�30 __� / 7 <br /> City � State ZIPS Time In Time Out <br /> Business Rep Title ®AM 0 AM <br /> /� /� GI1Vi fo• C[XyrCti A0.�W <br /> EE m 0 PM m 0 PM <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 /> f ° I 0 Active Q Passenger *'Generator <br /> Tire Count(Whole/PTE) Q Outdoor <br /> (fI IO Q Closed Q Altered <br /> GPS Latitude IH� - I,�J Q Hauler Q Indoor <br /> 1L R,I O Q Inactive Q Truck <br /> Longitude _ F. I_ I `.L I Q Planned ®OTR Q End-Use Q Container <br /> Business.Type (Fill all that apply).�J <br /> Q New Tire Dealer Q Auto Repair Q 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 ®Other LM�, �tgr <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility' ENFORCEMENT STATUS <br /> V A HAULING AND 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. 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 Q Referred/C-IWMB 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 Compliance - No Violations <br /> Q Q Other: §. <br /> Comments <br /> Ra-w--"—'RtY1S{ ��'' ars �"6.tY—tic Pa-1s rra(— R<,r i c_�/1LS oy— <br /> Inspection Form Included:Q <br /> Comments Included:Q �f <br /> Business Rep's ignat re Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: E X AjMP !L E l `2 3 62081 <br /> ■ White Cop.CIW B Yellow Copy Operator Pink Copy.LEA ® ■ <br />