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07319040175 <br /> eee <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMBB 181(Newew <br /> State CaliforniaSurvey.Form.- Page 1 1 5 . 1 0 7 3 5 8 5 <br /> Callfomla Integrated waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection Type (Fill one). <br /> Site Suffix: 1 3 5- 6 D ®Routine . Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: 5ca H � t n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> I R011- �inL. I — <br /> Physical Address <br /> 3 y � � � ^^ '' <br /> L/7�Gtytal4_B�.Cf7�'1� <br /> Street <br /> Inspection Date <br /> CA '9.5231 I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> PM ®PM <br /> .Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE): J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> y• , 7C�, <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS �J•�_� ___ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — —_I I -7 Q planned A OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EMENNFORCET STATUS <br /> V A HAULING AND MANIFEST REQ IREMENTS 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 (Required for NOV or EXl) <br /> 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/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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments ri'w <br /> nl�s.�wnirer�--- <br /> Inspection Form Included:Q � 01tUne <br /> Comments Included:QBus ep's Signature Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON OCK IEJ X A AM1 P L 1 2 3 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA <br />