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08248040022 <br /> ceo- <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> C1WM f 81(Nrnla Survey Form - Page 1 - I 1 10 8 818 0 <br /> CM'MB 181(New nage Y <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• p Inspection Type (Fill one) <br /> Site Suffix: -( f 5 Q I - © / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 16, 30.e. :N C.'W 7s c Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U [� Inspected By Inspector <br /> I ��.r�Ti,� cow ���✓ <br /> Physical Address 3 q - <br /> wOpB C�le�oke� <br /> Street <br /> Inspection Date <br /> Clit;' ZlP Ccde Time In Time Out _ <br /> Business Rep Title O AM i ��- i O AM <br /> 0 PM !— ---i .f --I- O PM <br /> - Operational Status Tire Type Business Role -Storage Type <br /> Tire Count(Whole/PTE) " (Fill one only) (Fill all that appy) (Fill all that apply) .(Fill all that apply) <br /> r r Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ Hauler Q indoor <br /> O *Inactive Q 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 i Other 171 4e— eov.y�O�}�/ I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENii STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> xtension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violatlon Q E <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXE <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 1 Q 1 Other. § e <br /> Comments <br /> 6/ s l `. ), 7:_&._ <br /> ZJ&.e 0,At ;4m'o <br /> Inspection Form Included: O <br /> Comments Included:O,' — <br /> Business ep's ignature Phone Number Inspector's Signature Phone Number <br /> — <br /> INSTRUCTIONS ON BACK or ect: 1 correct: EMM �p 1 2 3 62081 <br /> ■ While Copy CIW M Yellow Copy:Operator Pink Copy:LEA ® ■ <br />