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07354040046 <br /> =eo_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StaMB18te of ( rola SurveyForm - Pagel 1 4 - 1073493 1 <br /> CfWMB 181 New 04(04 <br /> callfomia Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ q Inspection Type (Fill one) <br /> Site Suffix: 3 !J 9 S / - •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ste, --�u „ ! Q CHP Q GIWMB Q Complaint Q Educational.Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address . / i Q / I i Q„v.__ J, _. <br /> Inspection Date <br /> 51ocKivY� CA gS'LOS - <br /> ;.,:. Time In Time Out <br /> Business Rep Title I Q AM O AM <br /> ' is PM 0P <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) fly (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appy) <br /> r /(J ®Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive )*Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) � <br /> Q 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 Q Hauler Q Agriculture Q Shredder ®Other L—Ar�_ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q iQ 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 /> 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 Gene rs ®In Compliance - No Violations <br /> Q Q 1 Other: § _ <br /> Comments 'I <br /> ��s^.�17�—)..1src..c�uti oew T�I.'�S�—'�?s'}•. _ — �!��/1��f.OJ't_�csy! <br /> �o�.s���Si.sa.2:�..�c/ZGf),_�_ •-f-rM�f'- �J s(/-�.zw�ee/—�!J�+-n_►�cS.�.. <br /> Inspection FormIncluded:0 <br /> Comments Included:Q <br /> Bus ess p's S' a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACrrect:9 Incorrect: ](� E X A M P L 1 2 $ 62081 <br /> ■ W ila Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />