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08227040113 <br /> = E,. Waste Tire Survey & Inspection Report Inspection Report Number <br /> State iG8 CTWM 181(New <br /> Survey Form - Page 1 I 1 10881087. <br /> CIWMB 781(New 0411)4) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- ' - I � , � �� _ D , Inspection Type (Fill one) <br /> Site Suffix: (� * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^/ � �� �yyJ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected ey Inspector <br /> Physical Address L_71LH/9�D�/y�J <br /> Street Inspection Date <br /> -� �52�s <br /> Git% ` �� State [!P Code Time In Time Out <br /> Business Rep Title I�O AM I 10 AM <br /> AI <br /> - — - Operational Status Tire Type Business Role Storage Type <br /> i ) <br /> Tire Count(Whole/PTE) (Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 8 <br /> t i Active Q Passenger Generator Outdoor <br /> Q Closed Q Altered . <br /> GPS Latitude Q Hauler Q Indoor <br /> I , , <br /> O Q Inactive Truck <br /> Longitude - ! ! ( Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0-New Tire Dealer Q Auto Repair le 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 Q Other ( I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> VA HAULING AND MANIFEST REQUIREMENTS Q Notice Of 1/lolation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co pliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 NO or FX7) <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 I 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 /•NE_LN [�tsa�'1-1f�� L3 _� Af- 119"+dwr^"&)a.. <br /> fC.dnGli 4L ��►J� <br /> —A <br /> 2_0 c7f <br /> Inspection Form Included: Q _ <br /> Comments Included: Q /�4~�-�896 <br /> B iness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co re t: incorrect: p E 1 2 62081 <br /> ■ White Cop CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />