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08157040087 <br /> �sr Waste Tire Survey & Inspection Report Inspection Report Number <br /> t0➢- <br /> r,➢ CrWMl81(N- Survey Form - Page 1 I S - 10 7 9 2 3 0 <br /> CIWMB 181(New 04/l1<) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� � � � � /) - D / Inspection Type (Fill one) <br /> Site Suffix: I , I 7 Q Routine Q Re-inspection: Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JQ an ""rn/ <br /> • -fy-� U/1�� Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name (/ Inspected By' Inspector <br /> Physical Address -/ 110J.t] L _/ A44PfA <br /> Street <br /> Inspection Date <br /> Isfa.�-1-ar► C� 95206i V <br /> City State1p��e Time In Time Out <br /> Business Rep. . Title 0 AM 0 AM <br /> 'm O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 0. <br /> Tire Count(Whole/PTE) I ! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ° 40 Active Q Passenger f Generator Q Outdoor <br /> GPS Latitude - I 0 Q Closed Q Altered <br /> l _I•�_ I_ I� Q Hauler Q Indoor <br /> I r r 0 Q Inactive Q Truck <br /> Longitude : �_I. 1 I I I Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 I <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 Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 40 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility ENFORC-EMENT STATUS __ <br /> V j A HAULING AND MANIFEST REQUIREMENTS Q Notice Ot Violation 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. 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 EXT) <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 Referred/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 111111In Compliance - No Violations <br /> Q Q Other: §. <br /> Commentsyp7_�yr_[/JiS QC /t-_-•—J/' [���GppJ����r. �] <br /> IiY <br /> � <br /> pl;;v <br /> Vie �-.a LSC s T V_�'Gw A�D—✓_ib/ o�S-d <br /> Inspection <br /> Inspection Form Included:QI d� - <br /> Comments Included:Q Busine s_p's S gn lure phone Number Inspectoes Signature Phone Number� <br /> INSTRUCTIONS ON BACK C reel: Incorrect: 62081 <br /> Ex .a �hPLE� s 'z � <br /> ■ White C y:CIW Yellow Copy.Operator Pink Copy:LEA ® ■ <br />