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09049050022 <br /> ® Waste Tire Survey & Inspection Report Inspection Report NumberStat.of . <br /> dornia <br /> CIWMB 81I(N—M04) 1 1 <br /> Californialntegmted Waste Mariagement Board Survey Form - Page 1 T 1 10 8 8 3 7 0 <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� - D ) Inspection Type (Fill one) <br /> Site Suffix: ) IL�i, 1 Q Routine ®Re-inspection Q Referral Q Observation <br /> 1 <br /> Local ��jn'^ If Referral,choose referral type(Fill one) <br /> Identifier: V W I �O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ J <br /> Business or Facility Name ------ <br /> o—0 ,, � p Inspected By Inspector <br /> -r�YlidLils _� (�)p/�'/` es }� tPhysical Address 1 I � - V f� 3 � F/. t��ti <br /> �,�t h rr1' <br /> Street , � <br /> y1 (������J111•••/'�� Inspection Date L�r/1 <br /> %it), =` --` State ✓Z/IP Code i Time In Time Out <br /> Business Rep Title O AM O AM <br /> fV/n M: <br /> 0F;M �' 0 P <br /> -/'t _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill oneonly)- (Fill all that apply) (Fill all that apply) '(Fill all.that apply) <br /> ° Q Active Q Passenger Q Generator Q Outdoor <br /> ..-•i f... .I ; <br /> l r O Q Closed Q Altered <br /> Latitude <br /> GPS - •I_—l_-'- J__I Q Hauler Q Indoor <br /> -._I r--- --?-- O IS Inactive Q Truck <br /> Rude I Q End-Use Q Container <br /> Longitude - iT ; (.I I I I Q Planned Q OTR <br /> t <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 Ly�Qy <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT/ST—ATU_S <br /> V q ;HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 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 <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 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!C-IWMB 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 1 Other. § <br /> Comments -he Vi Si f -44;'s c/ttw' <br /> 1 64- ' h s �SCLGQ�clre�s�s-- oC�.tir'i n _�o cis f -2> � <br /> i� s `yns;;r- _iCh c��-�clyi ) fi`on nP 12S LI- 83 — <br /> oil ask -?i re, 6 1 It ori VJ aste r r/Le. <br /> Inspection Forth Included: <br /> 7 mg <br /> Comment ® f ` , NVn n r QBusiness Rep's Signature Phone Number Inspec r <br /> Signature_ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A P 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />