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08206040136 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> swteed aisteM Survey Form - Page 1 Ir�1--9- 1 0 7 9 2 4 8 <br /> CMlMB 181(New 04100) - \/ ('J - <br /> Calitomie Integrated Waste Management Board J `�,/' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- I 1 I Inspection Type.(Fill one) <br /> Site Suffix: �' 0 Routine Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - LO-CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> Street <br /> Inspection Date <br /> I L.dcQi G� 45 Z'/0V <br /> ity State ZIPCode Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 7 A-- FTI <br /> 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 all that apply) <br /> 1. IJ <br /> I0 Active Q Passenger 0 Generator. 0 Outdoor <br /> l O O Closed Q Altered <br /> GPS Latitude W, 0 Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government- Q Retreader Q Dismantler 0 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 0 Agriculture Q Shredder 0 Other <br /> Part B-Inspection.of Waste Tire Dealer,.Generator,Hauler-and End-Use Facility RESEMROMOIENT.LTATUS <br /> A HA IN6 ANI E M EM-NTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Gompl ante •eadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 • 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within.90 days (Required for NOV er EXT) <br /> O O 14 CCR§18459.3-'Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0. 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In mpli ce - No Viola ions <br /> 0 Q 1 Other: § <br /> Comments �_ er✓• 'est/ dY1 OYL—�e aCat.Tt__/t�' �, `��✓�j al.�G� <br /> �r S G uA-•i�t+D Nov �i s rs./`r�+►n 3 rJ r ![dYe/ eo.t r...J �o�. <br /> O� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> usmess Re 's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre Incorrect: E X A M P L111'2131 <br /> ■ White Copy:CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />