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0.9.280040781 <br /> LHil. Waste Tire Survey & Inspection Report . - Inspection Report Number <br /> 11 CFwMState f 81(Now Survey Form - Page IEC4 - 1. 0 1 0 8 8 4 <br /> CIWMB 181(New 04/04) - <br /> Califomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- m Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s/t)�J IJ -A j 6-6yk � O-CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (f — - - - - <br /> I Qvyl,+,) CA2ticrs Inspected By Inspector <br /> I <br /> Physical Address 3 I / V <br /> 2&-�-O O S • � A N rA - <br /> Street <br /> I T(� C�4 gS3o� I Inspection Date v <br /> City ti State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 7 ik •e �lN,tyl "•Q O PM m ' m O PM <br /> �ehh 1-'5' r� je4; ICit4 TYt <br /> t f � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L1 =. <br /> l"" (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 41 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m• 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 0 Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator,Hauler and End-Use FacilityENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0. 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX1] <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments f <br /> it_Gra--A-A-4 <br /> -rltatiu ��e• 71� ,s a ,Jew CL <br /> �u <br /> 7�P � e� — -�' o ✓�alb�s or C _cw�s <br /> ct _�orr-4,Q <br /> inspection Form Included: 0 <br /> Comments Included: 0I <br /> 468 %'A)` ess Re s St na re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C rrect: Incorrect: X hh A P '1 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />