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08066040039 <br /> Waste Tire Survey & Inspection Report Inspection Report.Number <br /> 5�`°°" SurveyForm Page 1 1 1 - 10 7 3 4 2 5 <br /> CIWMB 181(New a <br /> Caliromla Intepmted Waste Manageaga ment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site • IJ ,l _ O Inspection Type (Fill one) <br /> Site Suffix: I 11 5 h�I Lf ®Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local <br /> L::�` ���C=� n � If Referral,choose referral type(Fill one) <br /> Identifier. l ` 0 CHP 0 CIWMB .0 Complaint 0 Educational Visit 0.Other <br /> Business or Facility NameInspected By Inspector <br /> t <br /> Ph real Address <br /> _(p S_D <br /> Street Inspection Date <br /> S7 o06 Ili 9 50213 , <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title :MOAM 0 AM <br /> Ww'N•S4 m mOPM m m 0P <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 /> Active 0 Passenger ®Generator ®Outdoor <br /> l 0 0 Closed 0 Altered <br /> GPS, Latitude J, 0 Hauler 0 Indoor <br /> �����J — O 0Inactive I&Truck* <br /> .Longitude - F � I, 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) J <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ®Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I , <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility: ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m / m <br /> 0 l 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 0 Other: §, <br /> Comments ROICtaV_ +� ft, 60[&n 131S removed /s/ lgZzs <br /> f//W 69- ebT 6rm i 6wed . 5740 j; y ri epi Oe,L lemic ss {ro►v1 3_E4 Vl i es <br /> l Drax ►�al l an <br /> per l -A _ole WQsfe tzr� . ',�✓�o>ts <br /> ' rr , "&'o�rr SIG Ices viewed p 'ol*4VAs Aoted <br /> Inspection Fo Included:0 I r aW -b /� I `�✓ rt,q9_6 3 j q L & /9YJ& <br /> Comments is Included:0 U <br /> Business Rep's Sign re Phone Number Inspector's S' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:X& q RX A M P L E 111213 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />