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08206050017 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> State of Survey Form - Page 1 11 - 1 0 7 9 2 6 5 <br /> a CFWMRevMB 161(new 04104) Y <br /> California Integrated Wears Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( a �rTInspection Type (Fill one) <br /> site Suffix: `f�— 11 T& 1 D Q Routine Q Re-inspection Q Referral 19 Observation <br /> Local r– If Referral,choose referral type(Fill one) <br /> Identifier: �/}n) �8/4�t�fl/✓ 60AJ Q CHP • Q CIWMB Q Complaint Q Educational Visit.Q Other <br /> Business or Facility Name U Inspected By . Inspector <br /> I C�Mf_x 1 3 9 - <br /> Physical Address �(���E i <br /> I 3D315ro S. -n Bled. I - <br /> Street I Inspection Date <br /> T g s3 � c, <br /> City State ZIP Code Time In Time Out <br /> OA 0 AM <br /> m <br /> Business Rep- Title m m 0 PM m 0 PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I Q Active Q Passenger Q Generator Q Outdoor <br /> GPS I <br /> Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0Inactive Q Truck <br /> O Q container nerLongitude Planned Q OTR Q End-Use <br /> Business Type (Fill all that apply) L �I <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 /> i Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATlU_S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 Date m / m / m <br /> Q Q .14 CCR§18459.1-Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required 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/61 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 mow, ,_ A mr� Tt�— a u. P�j kas�Lr aQ ec u. <br /> HdeLb a._9 <br /> Inspection Form Included:.Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orreo nsorreta: E X A M P L E! 11[,1131 62081 <br /> ■ White Co .CIW M Yellow Copy Operator Pink Copy:LFA <br />