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08129041071 <br /> ere- <br /> Waste Tire Survey & Inspection Report 4rispection Report Number <br /> State rr CIWM 181(arala Survey Form - Page 1 1 1 - 10728561 <br /> CIWMB tat(Haw galea) - <br /> Callfomla Integrated W-1.Management Boartl <br /> Part A=Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site suffix: I 3 15 17 �� I - 0 Routine .Q Re-inspection Q Referral Q Observation <br /> Local � -�-^ / If Referral,choose referral type(Fill one) <br /> Identifier: . Fs" O/� jr/ ( OVN i t� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> =j <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �6P.t.P le--o,se mr T-A)c- <br /> Physical Address l [3R] <br /> I //3 <br /> Street Q <br /> Inspection Date <br /> s-1a Fan el- 9SZ�G I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> O PM m 0 PM <br /> _tit -a � --- t•,«_�r Q_.j <br /> Operational Status Tire Type Business Role Storage Type-. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 <br /> ®Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude �—I—I.I_ I I Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> Longitude - 1 I�I I 'I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 <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 0 Other LT � _�MP9�t1 —J <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFOR_C-EMENT S_T_ATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - �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 <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 EX l) <br /> Q O -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 1 Other: §, <br /> Comments ouT7�E %�✓�c�{' ?j (yam fry <br /> y� .t,6,�= errs •`tri,(/ <br /> //- / 7"&1 <br /> (/o <br /> _lyf Q�►L./_ S !/%u�/ ...__ — l//O�t lir i?YtS __rte h S Vd_T ar <br /> Inspection Form Included:Q <br /> Comments Included: <br /> 01- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C• t:� ncorrect: Ah IX a P L E111,2131 62081 <br /> ■ White Co y'CIW Yellow Copy:Operator Pink Copy LEA ® ■ <br />