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48129040964 <br /> cee_ <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> 7�r <br /> CIWMBCalifornia Survey Form - Page 1 11 - 1 0 7 2 8 9 7 <br /> CM/MB 1111(New 04104) ' <br /> "adromia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i TPID- Ei <br /> (nom _ Inspection Type (Fill one) <br /> Site Suffix: Et - 151,z ! \J f *Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 �^ If Referral,choose referral type(Fill one) . <br /> Identifier: S",3 � vA A CCU pJTU O CHP Q CIWMB Q Complaint Q Educational Visit Q Other.. <br /> Business or Facility Name VInspected By Inspector <br /> Physi A dre <br /> IStreei o��_a _S' 1.�i1�o.��-C,—L✓I—J. MOg <br /> �7rInspection DateCity �� State 5Zlr'OCode Time In Time Out V <br /> —J—] = <br /> Business Rep Title Q AM O AM <br /> 0P 0P <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(W hole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger I®Generator 4P Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude [_J['_ I ---'� O Hauler O Indoor <br /> I L ��— 0Inactive Q Truck <br /> l — O <br /> Longitude L-- 0 Planned Q OTR O End-Use O Container <br /> L_TT_ 111 <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer Q Auto Repair O Trucking Fleet Q Government . Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> I <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture O Shredder O Other I I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> O O O Notice Of Violation Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[I] / ME / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-ompliance - o Violations <br /> Other: §, <br /> Comments <br /> -/ /�•4 Ula ds�.s_p�c�,!1II4 S u�/�'/ ��L�_cf-� <br /> !_e_ <br /> Inspection Form Included:O A Q <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct: Incorrect: E X A Ah P L ; 1 2 3 <br /> ■ White Copy. IW Yellow Copy:Operator Pink Copy.LEA ® . <br />