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03870" 02 <br /> Waste Tire Survey & Inspection Report 3 <br /> en_ <br /> Inspection eportl urnber ■ <br /> rr Stateof-tomia Survey Form - Page 1 .) 9 - 10 7 9 1 5 7 <br /> r CIWMB 181(New 04!04) Y <br /> calltomla Integrated Waste Management Board <br /> Part A.Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- LlL3 <br /> iYJ <br /> 3 ,e � - n / Inspection Type(Fill one) <br /> Site Suffix: (p V Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -dk4 M If Referral,choose referral type.(Fill one) <br /> Identifier: �N J. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> r <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ph Ica! Address <br /> 6d0/ <br /> Street l I V <br /> Inspection Date 3 <br /> �,cc C4 124 9523/1 <br /> �fly Mate ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ��V_£._�7-P�/_IyJ__ �L_. _ ��►�J m.m O PM EE.: <br /> m O PM <br /> l Operational Status Tire Type Business Role' Storage Type-. . <br /> j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f f <br /> I 0 Active 0 Passenger &.Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> -- 0 Inactive 0 Truck <br /> T <br /> O <br /> Longitude - 1. -I I Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection .0 Crumb Rubber <br /> 0 Service Station. 0 Hauler 0 Agriculture 0 Shredder 0 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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and.Transport of Tires <br /> 0 0 PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0' 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 1010 1 Other: § <br /> Comments is 414s A �ouT7�t-4 iA.) XC.o1-,,a► o��_/�2tis /r s-t.�-��-- •�kG <br /> t✓_.=.11�—.��vs�'f_s./�� - —fit 6l. _�/fie i,��C,t•f ccl us �7i,�T i.��.s <br /> Tles A4%1 W4zI's v0 T,A" 00 Arf- AAE We' <br /> 14ersk40 -,S, -5�w•. ✓_�v s e� 9 lE /✓a ✓�a/4rr ' ,Jct <br /> Inspection Form Included:0 .A <br /> Comments Included:0 — <br /> Busi s Rep's Signature Phone Number nspector's Signature Phone Number. <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(1� 9 110XjA�Mj,e[LjE1 1112131 <br /> 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br />