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08151040014 <br /> rrr- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CnNM B 181(New 04104) Survey Form - Page 1 1 4 - 1 0 7 9 2 0 2 <br /> CIWM <br /> caliromia Intograted Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- O - Q / Inspection Type (Fill one) <br /> Site <br /> Site SufFix: Q Routine Q Re-inspection Q Referral 40 Observation <br /> Local �t� /t If Referral,choose referral type(Fill one) <br /> Identifier: I 'S"'ej Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ale.t)i^ 19401�Inspected By Inspector <br /> IGo^�PAn1 y/J; _ , 'w `/•\ <br /> Physical Address J 3 9 F/To / �_ R � <br /> L 220 ( W K)As h„ �T <br /> Street D 3 / O 8 / D <br /> Inspection Date <br /> —C RSZo <br /> City State Z!P Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m• FU O PM � •�__ 0PM <br /> i <br /> dy <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 /> FTir0 <br /> e Count(Whole/PTE) <br /> •Active Q Passenger 0 Generator 0 Outdoor <br /> Closed Q Altered <br /> GPS Latitude I—'•� I Q Hauler Q Indoor. <br /> QInactive Truck <br /> Longitude I 1 I i Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A iHAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m / m <br /> Q O 14 CCR§1B459.1-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 O 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/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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments ` <br /> --Lt-f,1-•N�-int <br /> �,✓a-a- .�.b%��•' �5c,,'G' �sts G<1,_!_sy_fres�4 <br /> % c5 T�1�-- •'r`G _t'!a�!�/ �V-a��?��A-P�'U�—Aid- C'AnC191"s <br /> Inspection Form Included: Qil 4(Q <br /> Comments Included:Q -- �nspe.t.r'sness Re ' ignature Phone Number nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correc Incorrect: ( Ir XAMP L E 1 2 3 ® ■ <br /> ■ Whit Copy CIW B Yellow Copy:Operator Pink Copy.LEA <br />