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f- <br /> 03038040307 <br /> eee_ <br /> Waste Tire Survey & Inspection Report . Inspection Report Number �. <br /> 114 State of California <br /> " CIWMB181(No.04104) { `r�`V - 1 0 7 9 4 2 6 <br /> Cllfomia Integrated Waste Management Board Survey Form - Page 1- <br /> Part A-'Surve BLUE OR BLACK INK PEN_. <br /> Business Profile Inspection.Details <br /> TPID- Inspection <br /> D O 3 Z - O I Inspection Type (Fill one)Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� -�c,q��ty� Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name V` Inspected By Inspector- <br /> Physical Address � p � n <br /> -7 <br /> L—Z9 S-0 <br /> Street <br /> Inspection Date <br /> Cts <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m' <br /> MOPM m'm ®PM <br /> OperationahStatus 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) i <br /> ®Active Q Passenger 0 Generator ®Outdoor <br /> Latitude L I I LO Q Closed <br /> GPS <br /> Altered <br /> P$ Q Hauler Q Indoor <br /> ---I —_ -__ O Q Inactive ®Truck <br /> Longitude - l I I T] Q Planned Q OTR Q End-Use Q Container <br /> - )-- �-—� F I— -I- <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 <br /> Q 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 <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 EXTJ <br /> Q ®- 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/C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> -Manifest System Requirements for Tire.Dealers or Waste Tire Generators <br /> Q Q 14 CCR§18462 ®In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> CommentsQ <br /> ilLI arc <br /> -�rlYr-•�.Pl-��J��/�t!_/_:j,QLL'�- _. � `1.Q1,.<.<C_r/--�[Lck�h•fsii/ rte_-!.t•.�,r <br /> —�rJ%ora—�� ►— — -. tec rs 111 'V'Ca lz �y�`E Spy. 3 <br /> I <br /> Inspection Form Included:Q <br /> x 7`� <br /> Comments Included:QBus s�Sigjnat <br /> Phone Number Inspector's Signat Phone Number <br /> INSTRUCTIONS ON BACK Correct: ncorrect: 6zoB1 <br /> K AIM P 'L EI, 112 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I _ _ <br />