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07312040463 <br /> r„ <br /> Waste Tire Survey & Inspection.Report Inspection Report Number <br /> ;r <br /> State of <br /> CMIMB 1a1 181( 04/04)omla Survey Form - Page 1 1 4 - 10 7 3 5 3 5 <br /> at <br /> CHomia Integrated Waste <br /> te Manaeament Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Z $ � 6 O ' Inspection Type (Fill one) <br /> Site Suffix: 1 3 ®Routine Q Re-inspection . Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S 30 urs— Q CHP Q CIWMB Q Complaint .Q.Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector. <br /> I I'_V IL— ' I <br /> Physical Address - O �- L— aMOf <br /> Street m <br /> Inspection Date <br /> m m <br /> City Sr 9State°6ZfP Code I Time In Time Out <br /> Business Rep Title m' <br /> MIOPM m'm ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (�, (Fill one only) (Fill all that apply) (Fill ail that apply) (Fill all that apply) <br /> (6 Active Q Passenger Q Generator Q Outdoor <br /> ! I O Q Closed ®Altered <br /> GPS Latitude , 1_ Q Hauler ®Indoor <br /> l—�_ 1 <br /> O Q Inactive Q Truck <br /> gitude -� <br /> LonQ Planned Q OTR ®End-Use Q Container <br /> - _ 1 <br /> Business Type.(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet . Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <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 I HAULING 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 E>M <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 f 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 1 Q 1 Other: § <br /> Comments <br /> Jl_u01co—ltScs 9iai4.,a�or—a.�k�•! <br /> �/i�/Y-/h_c2r.�.tF�/f�v_tr_r—�L/c�4.,ft/o_r_r�'i/_c._�O�ir�r��i•,•,�-;Jrrad.,e.-.- atrC_-�Gi✓ <br /> Inspection Form Included:Q �( ^ <br /> Comments Included:QIrsSigIr1�w� yd -a6 Z3 <br /> Busine ep's Signat o umber Inspectonature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA K Cor ct: Incorrect:KA(� E X A AA P L E 1 2 3 <br /> ■ White opy.CI M Yellow Copy Operator Pink Copy LEA ® ■ <br />