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09210040247 <br /> Waste Tire Survey-& Inspection Report . Inspection Report Number <br /> state of California' Survey Form - Page 1 1 4 - 1 0 7 9 3 4 2 <br /> CIWMB 181(New 04104). <br /> California 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: (D ' a $] ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � , If Referral,choose referral type(Fill one <br /> ) <br /> Identifier: 0 CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> u1 Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> S+o O �1 <br /> 111 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0AM U C� 0 AM <br /> `n 1_ Sly Far(,,m� 1 i • PMEU 1 J 0 PM <br /> Operational Status Tire Type. Business Role• Storage Type <br /> i'_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ' 1 (3 <br /> f I . (aLatitude Active Q Passenger ®Generator •Outdoor <br /> � I � • <br /> O Q Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> II__ O Q Inactive ®Truck <br /> Longitude — IT •FIFITT- 1- Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that applly) <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 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice of Violation Q Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <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 orEXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> \ 1 \ 1 <br /> Comments <br /> 0cA�C�I_�� <br /> S r <br /> Inspection Form Included: Q _ _^ ,AComments Included: Q- //ny�$t/�J �ilsiSignature <br /> � ��� <br /> Businss Rep pae Phone Number Insphone Number <br /> - <br /> INSTRUCTIONS ON BACK C rrec '* Incorrect: ( fi MIV X R P L 1112 3 62081 <br /> White Co y.CIW Yellow Copy:Operator Pink Copy.LEA <br />