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-- Waste Tire Su 'y & Inspection Repor. Inspection Report Number <br /> t Eli9. <br /> State of California I 1 - 11412 4 2 <br /> ClWMB181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> !Business Profile Inspection Details <br /> TPID- �+ � � � � O I - NE Inspection Type (Fill one) <br /> Site Suffix: ,' I* Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �1n Q CHP Q CIWMB Q Complaint- Q Educational Visit Q Other <br /> Business or I Facility Name 1 Inspected By Inspector <br /> yG l AddEd 1 b 1 �Physical d [-�Fq-� ��C!_)_ <br /> Street 1 �t-•-r I / <br /> aaInspection Date v c/J (L 1• II <br /> Al—A\ �� State ZIP Cotb de Time In Time Out <br /> Business Rep Title 0AM l� (, AM <br /> DIN ' L ► O SPM I�_i ' V� ®PM <br /> . _ -_ <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 /> ' ' I Active ® Passenger -Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I I I , � 1 i {�—�—) Q Hauler Q Indoor <br /> W I Q Inactive Q Truck <br /> Longitude - ( I I I Q Planned .Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 10 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 Q Other I I <br /> Part B = Inspection ofWasteTire Dealer, Generator, Hauler.and.End-Use.Facility � NFb,RCEMENT,STATUS ��a � „ <br /> �V <br /> k� ,A— ''OA UL•ING%1ND„MANIFEST:REQUIREMENI'S ,;_��# ����,;��� ��3�-� ,� ,,�„�x � �„ <br /> ,Q Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires . Wln <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0oma% 4 @tt �� i sz rds�SS�a <br /> PRC§42956-Registration/Decal in Vehicle. <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date" <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> x f&, <br /> irbd <br /> (Requ , r V or � <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days. �� �,� 4 ���� <br /> , � aT+a °esu a <br /> Q Q 14 CCR§ 18459.3 Retention of Comprehensive Trip Logs for 3 years •J� � <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ;Referr�ed/CIWMB" Enforcements' . <br /> �.F� mak'*ar�a,y�a� �rmxtk Me F �4ss.Am <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 5,s x v: be <br /> ®�In Compliance �'NoViolations <br /> O O Other: <br /> Comments ��� ��Ute_ �— �S_ _ .��� Q11[1�-n -►-�-�_�_ �• — <br /> t <br /> 00\ -04—or <br /> Inspection Form.included, Q <br /> Comments Included: - <br /> Business Rep's Si nature Phone Number Insp or's ignature �/ Pion—e Number <br /> 5,71 N7 <br /> INSTRUCTIONS ON BACK Co Aectncoirect )r 'q1']jEjX A ,Nt R �� 1 .� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />