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08137046141 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> State ClWM <br /> fleCaliforniaaiSurvey Form - Page 1 1 2 - 10 7 9 2 2 5 <br /> CIWMB foew 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 4tq <br /> ^� _ O / Inspection Type (Fill one) <br /> Site Suffix: L /f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Di4Ki,; Q CHP Q CIWMB. Q Complaint .Q.Educational Visit Q Other <br /> Business pF�acility Name L Inspected By Inspector <br /> PhyL sical'Addr4ss ��7 I [317q- F/To-T/I ?,4., Y44,pa-v _j <br /> - <br /> o <br /> Street Inspection Date b / <br /> 67— cam- State ZIP Co e q52� <br /> Cify Time In Time Out <br /> Business Rep Title <br /> II0� AM 0 A <br /> QPM 0 PM <br /> -- - -- _J Operational Status. Tire Type: Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active +Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I <br /> I I Q Hauler Q Indoor <br /> __I .__ <br /> 0inactive QTruck <br /> Longitude - I I ,I- 1 Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) 1 <br /> 0 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 O Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> Q QPRC§ Q Notice Of Violation Q Extension <br /> 42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 In Compliance - No Violations <br /> IIIIIIIIIIIIIIIII <br /> Q 1 Q 1 Other: § <br /> Comments <br /> cs_u1_.' <br /> _�.l�s'>✓d: �/ [_ _/..�a_1��yf �-��—��i—, /�i.� C.c�/i�ate'll�_� <br /> —� ' �a.� (/J-�c.tJ-Ld. lvoV_i�0_�aJ <br /> Inspection Form Included:Q qlo 7 <br /> Comments Included: Q — - <br /> Busi ess Re 's i natu ' Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corrects Incorrect: X A M P1112131 62081 <br /> ■ White opY CIW Yellow Copy:Operator Pink Copy:LFA <br />