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JE033�90�1� <br /> Lr7_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> rrl' State of California <br /> CIWMB 181(N..04104) Survey Form - Page 1 1 3 . 10 7 3 3 9 3 <br /> calfromla Integrated Waste Management Board <br /> Part A-S urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- O Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) . <br /> Identifier: �� Q CHP Q CIWMB_ Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. Inspected By Inspector <br /> ��u.h state St - 1 0 l ,li <br /> Physical Address U -9 aR <br /> I 2?oD0 Vi ctu��_ _ V�kuq I - <br /> Street �r�� � �,Q 4 r/n Inspection Date o ! / 0 3 / D <br /> I � 1��'�r 1"� `� f `��0�✓ I Time In Time Out <br /> (;fly State ZIP Code <br /> Business Rep Title m m 00 AM 0 AM <br /> PM m m 0 PM <br /> -- — <br /> n <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �, Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> LEO Q Inactive Q Truck <br /> � <br /> Longitude - —1 I Q Planned' Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) l _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 Q 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 Q Notice Of Violation Q Extenston <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 <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 FXT) <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/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 Fa6UJ-g has t'-elxAl-ed o IJeu) addre sus a <br /> 7 5 E. L q ap►Jen..f C-t <br /> ataa-fov, eLldq C15a31 <br /> OE <br /> Inspection Form Included%0 - rG <br /> 9p <br /> Comments Included:Q � - (gs-" C/ & <br /> Comments. <br /> Business _Signatur. - Phone Number Ins clots S lure Phone Number <br /> -- — 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: t= X A M P FC1131 <br /> '2 <br /> ■ White Copy:CIWMB Yellow Copy:Operator - Pink Copy:LEA © ■ <br />