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08129091121 <br /> Oft <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r, sa` "ca�„oma SurveyForm - Page1 1 7 - 1072829 <br /> CIWMB 181(New 04104) <br /> calHomia Integrated Waste Management Board <br /> Part A.. <br /> Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' n / Inspection'Type(Fill one) <br /> Site Suffix: 3 7 �(/ y - 1 at Routine .Q Re-inspection. Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: (!L Joe Cy Q CHP Q CIWMB .'Q,Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> I (i/ S' I <br /> Street <br /> Inspection Date <br /> 90 <br /> City /Jgta e —Tip—Code Time In 1 Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m'm 0 PM m'm 0 PM <br /> A40 -'"1A ✓ — t--- -- -- _ 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 /> � ��. �� ! � � j <br /> ®Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> 4771_171 <br /> O Q Inactive (®Truck <br /> Longitude - ,� Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection .Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other i I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST 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/Decalin Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <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 O --- - - - <br /> 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 0 Referred 1 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 /> 1010 1 Other: § <br /> 4 <br /> Comments I M4 r N.I.S Q l�(� `f112 74JL o t rw o <br /> Inspection Form Included:Q U!9 fj <br /> Comments Included:Q-� ` _ l [ <br /> Business Rep's Signature Phone Number Inspector's St ature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ](� E X M E I Z 362081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />