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080x0040181 <br /> LM <br /> Waste Tire Survey & .Inspection Report Inspection Report Number <br /> ■state of C.Itornia <br /> CIWMa 197(Naw 94104) Su rvey.Form - Page 1 1 3 - 1 0 7 3 3 7 7 <br /> California Integrated Waste Management Boara _ <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n,3 <br /> p1 JY�] <br /> _ Inspection Type (Fill one) <br /> Site Suffix: y ®Routine 0 Re-inspection Q Referral ..Q Observation <br /> Local �— If Referral,choose referral type(Fill one) <br /> Identifier. E�j�y� J bC� C Q CHP, Q CIWMB. .Q Complaint Q Educational Visit .Q Other <br /> Business or FacilityName y r Inspected By Inspector <br /> �,n.t,-�-,✓� � 5 /v a r�{'�t t,JP-Sr �h G' .3 q - � a l ��Jj"/'',� <br /> Physical Address <br /> I _0_9I E Cha� - <br /> Street e /�_ Inspection Date <br /> �— � �J�`''s� rime In Time!Out <br /> City Mate 1 Code <br /> Business Rep `� Title O AM Q AM <br /> ky_—/ _I� L _1�1.�2— m•m O PM m m O PM <br /> —__ Operational Status. Tire Type - Business Role Storage Type , <br /> ` j ( I 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) 'I I. <br /> JJJ (a Active ®Passenger ®Generator Q:Outdoor <br /> T O Q Closed, Q Altered <br /> GPS Latitude W, Q Hauler Q Indoor <br /> 0 Q 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 to Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> ------._. .._....... <br /> ........ <br /> V A111AAULING 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 m / Ell <br /> / m <br /> O 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 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!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 Other: § <br /> Comments M_H� )q ci Il0 _Lk)a.s YLOfed t- <br /> 7 s aw n l 4 ry asF-e E d i <br /> LS a vt oQ Ind r Ce5 <br /> JAY— 0A r'o /,a*2A <br /> a <br /> p.(S�S� LvO V i o �' —q+ <br /> Inspection FormIncluded: QI Cf <br /> Comments Included: — l-(- 1-�� <br /> Bu ess Rep's Signature Phone Number Insp or.'s Si n lure Phone Number. <br /> — <br /> INSTRUCTIONS ON BACK Correct: Incorrect: R A M P L 1 ,2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> - — <br />