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Q�25�440599 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWMB 81(New04104) Survey Form - Page e 1 I 1 - 1141180 <br /> California Integrated Waste Management Board 9 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I� <br /> �— ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ��•� If Referral,choose referral type(Fill one) <br /> Identifier: Sc,(1 � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> L D�11 t <br /> Physical Addre s <br /> W-1 <br /> St•eet �-7 <br /> -SkQ(-- - or Inspection Date i -I <br /> City State Z1, Code Time In Time Out <br /> Business Rep Title AM Q AM <br /> r' �n, • LO IOI� PM �� • C�-+� GPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 I*Active Passenger Generator Outdoor <br /> Q Closed Q Altered <br /> PS Latitude I 1 <br /> Q Hauler Q Indoor <br /> QInactive 0 Truck <br /> _i <br /> O <br /> 1 Q Planned -Q OTR Q End-Use A Container nerLongitude - I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair le 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 Q Shredder • Other 1 <br /> _J6 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT,STATUS <br /> ;V , A�LL'IiAULING AND MANIFEST�REQUIREMENTS. bra <br /> Q Notice Of ViolationQ#Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires w .a. <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q. § 9 Compl1lance. Deadline <br /> Q Q 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 . y <br /> ry .4111 <br /> (Required for N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> OVV",4 Cf) <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 Q Referred 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 I 1 <br /> ''p cQ—Uni -4- -- <br /> Inspection Form Included:.0 <br /> Comments Included: <br /> Business Rep's atu Phone Number Inspe is Signature Phone Number <br /> ,—/ 62081 <br /> INSTRUCTIONS ON BACK ,Co rest ,lncor�ect ( }( � X I AuMh I P I L 12 3 <br /> White Cop CIW Yellow Copy:Operator Pink Copy:LEA <br />