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08038040308 <br /> ■ er <br /> Waste Tire Survey & Inspection Report inspection Report Numb ■ <br /> at1 ClWIVI ISI(Na.CaliforniSurvey Form - Page 1 1 1 - 1 0 7 9 4 0 6 <br /> CNJMB 181(Naw 04104) <br /> callfomia Integrated Waste Management Board <br /> Part A-SurVe BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI <br /> Site <br /> - d q Inspection Type (Fill one) <br /> Site Suffix: L' y 3 I ! ( ®Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,.choose referral type(Fill one) <br /> Identifier: �C��._,. _r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or facility Name Inspected By Inspector <br /> I dr <br /> Physical Address 5191 <br /> Street <br /> Inspection Date <br /> I_—�!_uA.ti___--�i1�. _ _ CIS(o 3 a I <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleMQ AM Q AM <br /> m <br /> ®PM ®PM <br /> i 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) f r Z <br /> ®Active ®Passenger Q Generator ®Outdoor <br /> I 0 Q Closed, Q Altered <br /> GPS Latitude III, I � I � Q Hauler Q Indoor <br /> W L. —I —� Q Inactive Q Truck <br /> ---��__.— Q Planned Q OTR <br /> Lon nude I I I Q End-Use Q Container <br /> 9 � <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair (0 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 <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 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/Oecal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I Q Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 emequremenea <br /> In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> f�►'tK- -t�'lC}yc.Q�E--�cx+ c5Y_�_�[n�f_—�-�ss.�i.� 1��^,f[-a.�—t(�[_C(n-(��c�.y <br /> �r-�-s--�.►nfl�.rJ—��1J+-T-�wu..1. e?�x�-� Y,�x��n_ �-��. I��/ ��'s.� <br /> f <br /> P2_�irzt_4a?a.F�ec%c.� o_rs._S�k - <br /> Inspection FormIncluded:Q k <br /> Comments Included:Q ,�, i <br /> Buslne s Signature Phone Number Inspector's Signature Phone Number <br /> 62081 — <br /> INSTRUCTIONS ON BACK Corrct�l' Incorrect: 0 K la Ah P!L E1 1112 n3 ■ <br /> ■ White Copy.ClWMB Yellow Copy.Operator Pink Copy.LEA <br />