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07354040067 <br /> Waste Tire Survey & Inspection Report Inspection ReportNuinbei ■ <br /> Stale of California <br /> CIWMa 181(New Survey Form - Page 1 _ 1_ 7 - 10 7 3_3 6 4 <br /> Cellfomla Integrated Waste Management Board - — <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I j Inspection Type (Fill one) <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local /--yy�� If Referral,choose referral type(Fill one) <br /> Identifier: -O' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l/ Inspected By �--� Inspector <br /> Physical Ad r g P}^Zv)S2: I�1 <br /> 06 <br /> Inspection Date ' j a ; pT �o <br /> Time InTime Out <br /> Business Rep Title j—r !OAM I 1 O AM <br /> ;O PM ! OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ®Hauler. ®Indoor <br /> O 0 Inactive a Truck <br /> Longitude - 0 Planned OT II@ Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ®Government 0 Retreader 0 Dismantler o Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O --- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance • No Violations <br /> 0 1 0 1 Other. § <br /> Comments kin 10"Ric -y 'S A.T e-• f Iu�1Rt1'AI IS it rt 1-0 <br /> mobo E,RT Rd__i i-mla qP 7P1.br1135-y651-1 VISVielved .TYRS gen2vzd-gd oh <br /> Si_te��5 -Vel-oje SK s��r-0IRS.No"'�r►=�S` a1Y__e b b h-- 10 ;s AAal <br /> Inspection Form Included:0 X09 <br /> Comments Included:O!t/ Y�� —✓'—'��� �-ure <br /> Business Rep's Signature Phone Number Inspec is S--- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X� tr X A AA P LIE1 Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />