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09129041091 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> AAAA Stale of California <br /> AAA CIWMB 181IN—04184). Survey Form - Page 1 1 3 - 10 7 91 4 3 <br /> camnmlamAegrated Waste Management Board <br /> PBLUE OR BLACK INK PEN <br /> art A-Surve <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: I�� p 23 - ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local I / -T^ If Referral,choose referral type(Fill one) <br /> Identifier: C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name x <br /> R .��y`'� N Inspected By Inspector <br /> -Phl Addlress ��/ �n e 3 91 /IpI V -�'1�• -� I <br /> I / 9D 5p-e_c",P_4 Zd , <br /> Street <br /> G��/ y / Inspection Date <br /> 953 <br /> ity State Zip Code Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> IE: 0 PM FT 0 PM <br /> - j I AAOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 4 j Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! /; / <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude I I I Q Hauler Q Indoor <br /> -I `--- -- Q Inactive ®Truck <br /> O <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 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 <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 Viotatio Q Extens on <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 <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 (Requi ed for NOV or EXT) <br /> Q 014 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 Reterred/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 /> 1010 1 Other: - /'C,o,/m-ments U WI¢,Ke /kjS hOf� M I Ce <br /> TG(�L(�t� <br /> � <br /> l <br /> ed o 1��� ✓I a C�-fz: rt.o�-..�.� <br /> Inspection Form Included:0 <br /> Comments Included:Q / <br /> Busines Rep's Signature Phone Number Inspector ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:+♦ Incorrect: X R r►4 P,L E1 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />