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29G ��° <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ot181(Nrnia Survey Form - Page 1 2 - 1 0 1 9 1 3� <br /> CIWMB191(New 04(04) <br /> ealifomia Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ l Inspection Type (Fill one) <br /> Site Suffix: I j 3 �Q / ( g ` ®Routine Q Re-inspection Q Referral Q Observation <br /> Local. / T If Referral,choose referral type(Fill one) <br /> Identifier: 19Q � Q CHP Q CIWMB .Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street —— IRS] / [M,3 / O <br /> Inspection Date <br /> I (Slo_cjj�jv n_J—( 95a-oa <br /> City State Zip Code Time In Time Out <br /> Business R--epp�llee- Title 1/ 0 AM O AM <br /> {_h1l •m O PM m PM <br /> Operational Status Tire Type Business Role Storage Type . <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE), <br /> r ®Active ®Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude I -�I —I I I Q Hauler Q Indoor <br /> Inactive ®Truck <br /> l � I II0 <br /> Longitude <br /> I- I 17 1 Q Planned Q OTR Q End-Use Q Container <br /> I _..... 1111 <br /> Business Type (Fill all that apply)- <br /> 0 New Tire Dealer' p Auto Repair p Trucking Fleet ®Government p Retreader p Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other L�lS! ' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility KENRO.CEMENT STATUS <br /> y A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Requirod for NOV or EXT) <br /> Q Q <br /> 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 t 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 Q Other: § <br /> Comments <br /> 4 � ?`lr2 Ls � /Uew�,°d �n ;SSu.es. 0�n¢_4— T -Garl.l �layd oir Petr <br /> yi.eOJCW 4 CnILVA1 Otmx� G xthe Was rems s>+ead Aa,;Jer uki J 1213i a . <br /> 9U i _!!iQ la-- a _ <br /> Inspection Fonn Included:Q 2 99� <br /> Comments Included:Q ` 3!:7j95 ��a <br /> --- <br /> ness Rep's Si nature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Incorrect: E X A M P L E: 1 ;Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA ® ■ <br />