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08227040111 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State¢ea: <br /> Californi <br /> CrWMB 181(Now 04104) Survey Form _ Page 1 1088105__] <br /> California Integrated Waste Management Board <br /> Part A- Survey* BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- !' Inspection Type (Fill one) <br /> Site Suffix: LI �� (/ I - �I • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local pT If Referral,choose referral type(Fill one) <br /> Identifier: J.�j JOS �/ Cove/Ty� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I �STS S �cpztss L•H cs I <br /> Physical Address <br /> Street � <br /> Inspection Date o G <br /> Stste ZIP Code <br /> City C. SZO�_I Time In Time Out <br /> City <br /> Business Rep Title I I 0 AM i--� � 0 AM <br /> PM Q PM <br /> A W4,Ile- <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-allthatapply) <br /> � /6"/) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Is 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 4P 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 Facility ENFORCEMENT STATUS _ <br /> V I 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 <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 0 Other: § <br /> Comments d I <br /> Inspection Form Included: 0 �20 <br /> Comments Included: 0 - "�L . <br /> ne Rep's Signature Phone Number Inspectors Signature Phone umber <br /> 62081 <br /> INSTRUCTIONS ON BACK I P/Orrec)0 Incorrect: ( E X A Ah P L E: 111213 <br /> ■ Whit Copy Yellow Copy.Operator Pink Copy:LEA ■ <br />