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09049050029 <br /> ® Waste Tire Survey & Inspection Report .' Inspection Report Number <br /> C1WM 181(N.w Survey Form - Page 1 I1 1088269- <br /> CIWMe 181(Naw nag4) y <br /> Callfomla Integretetl Waste Management Board <br /> Part A.Surve ' _ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O I Inspection Type (Fill one) <br /> Site Suffix: TILL 11�_1111 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: fr7�Q(7utf1 Cmtn 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> l a o,>)i Gl�i Quu�i�_y Ti(cS Gn c�—�V;eel I _ �y� <br /> Physical Address 3FiTo J+ L l.[scyi L/ � <br /> �QD S- Crag -- <br /> Street <br /> Inspection Date <br /> city cA State ZIP Code Time In Time Out 1 <br /> Business Rep Title Q AM j� 0 AM <br /> [Kt]) ®PM 3 v ®PM j <br /> ��:c�o� (Y_►u_.c5el�i_ ._6�1q�a_2� _ _ <br /> ----- - - Operational Status Tire Type Business Role Storage Type <br /> i l (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill-all.tfiat apply) <br /> Tire Count(Whole/PTE) I R <br /> �� ®Active ®Passenger �Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude -j_ . �.I —i i -J I®Hauler 0lndoor <br /> 0 Inactive 0 Truck <br /> Longitude I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel j <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> i <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I j <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT S1TATlU_S <br /> HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extensio <br /> Q 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires I <br /> 0}.:0lI,PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 :14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0.1 014 CCR.§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End=Use Facilities <br /> 0 )K 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ampliance - No Violations <br /> 0 10 1 Other: § 1 <br /> CommentsDn clar . on ,JW :al, ad b �t uW _ 1ryl 1, r\ l <br /> �� � <br /> � 95h �4r kt 4;('.5 (,e) -5�r - E(ST flit- n: e A -fauns -�lJ��1 bI� �o n <br /> c � s rY1 I 4, i A,i la�I + k Sf <br /> �u <br /> Inspection Form Included:0 <br /> Comments Included:0 . — -� ��I� 6H), <br /> Rep's S ture Phone Number InspectoASIgn.1 ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> � E. X � AhPLE 1 ;23 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />