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03227040185 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> SureMB18California Survey Form Page 1 11 - 1 0 7 3 4 4 7 <br /> C M/MB 181(Naw nage <br /> 4104) <br /> Calilomia Integrated Waste Management Board. <br /> Part A--Surve BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID � � ` ^ � � � - O / Inspection Type (Fill one) <br /> site Suffix: J L 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> ldentifier; �U'j 7 Q CHP Q CIWMB Q Complaint Q.Educational.Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical /Address' C. VV4y. - 40 ( <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In w Time Out FTI <br /> Q AM <br /> Business Rep Title AM <br /> m• m0PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)i I�yf; (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> _ Q Active Q Passenger Q Generator Q Outdoor <br /> r� O Q Closed Q Altered <br /> GPS Latitude W, Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other L/�1aTx. . {Ttlr—J <br /> Part B-Inspection of Waste Tire Dealer;Generator, Hauler and End-Use FacilityENFORC--EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q QPRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 <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 DCT) <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ------- <br /> 0 <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 Q_LHL AS��i�—A'Y_r_ /�—���_._� <br /> —}�.t.•I,��d�.—��- -ao r q•--t�,�.o.�Z-__�� lea,.,/ ,j�,�, �,/�� �t.��a� <br /> _PUG�o-7-a��O w1•�,w• Cd/U� �o G_��2 �1c1,�T,•��..._—.Gv_c p-�r?i_+�'_ <br /> 4t*= <br /> inspection Form Included:Q j� <br /> �c Zat( 8 X63 <br /> Comments Included:Q— <br /> B iness Rep's • nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Rrrect: incorrect: WA <br /> X A M P 1L l ] �2 3 <br /> ■ W hite opy CIW Yellow Copy:Operator Pink Copy.LEA ® ■ . <br />