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0825254053003 <br /> CA9- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> "' State of Callfrrrnia I 1 - 1088190 <br /> CIWMB 181(New04/04) Survey Form - Page 1 <br /> Calilomia Integrated Waste Management BoaN <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- / Inspection Type (Fill one) <br /> Site suffix: to 3 Y 1 :2-1 0 ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility N-a�mee.yt Inspected By Inspector <br /> Physical Address - �J � <br /> 23!8 Z-D_2�AJ_a " <br /> Street �1 <br /> Inspection Date <br /> ISTo-�± 4 5 V <br /> rty State ZIP o e Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 1 • O PM �J Q PM <br /> nn <br /> �- --- Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) -(Fill all that apply) (Fill all that apply) .(Fill-all that apply) <br /> r ° Q Active Q Passenger Q Generator Q Outdoor <br /> '-i0 <br /> Q Closed Q Altered <br /> GPS Latitude JI <br /> Q Hauler Q Indoor <br /> 0 Inactive Q Truck <br /> I' <br /> O <br /> Longitude - i ii iQ Q End-Use Q Container <br /> 1 1 i i Q Planned OTR <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 Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O.-Shredder 40 Other I +e.�102r �A&J J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANfFEST REQUIREMENTS Q Notice Of 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 Dme <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 FJCn <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 eferred 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 <br /> ti�� <br /> �.#"f 1 Q- <br /> &,cf <br /> Inspection Form Included: 2� <br /> QComments Included:Q 46s TSI <br /> to <br /> Business Rep - ture Phone Number Inspecr's Signature• Phone.Number <br /> A r 62081 -. - <br /> ■ INSTRUCTIONS ON BACK Co reef: neorreet: E X;A IRA P L -1112-13-1 <br /> While Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />