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08073040183 . <br /> CIWMB <br /> Waste Tire Survey & Inspection Report Inspection.Report Number <br /> State B 787(New o1/04(California - Survey Form - Page 1 { 9 - 1 0 1 0 8 4 8 <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J v If] _ r Inspection Type (Fill one) <br /> Site Suffix: / � 3 101 J T 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q ,'J„ O CHP Q CIWMB Q Complaint Q Educational Visit Q Other- <br /> Business or <br /> ther•Businessor Facility Name Inspected By Inspector <br /> Physical Address I 3 F/F4Q7 L �'�Z "✓?STI <br /> I u2 7// - <br /> Street <br /> I� „ N Inspection Date <br /> I cJ( D Q Q <br /> (�C 93'06 <br /> City State Zip Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> Q PM Q PM <br /> — <br /> _._ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ! 1 I D (Fill one only) (Fill all that apply) (Fill'all that apply) (Fill all that apply) <br /> f I 0 Active 0 Passenger 0 Generator ®Outdoor <br /> _—��O 0 Closed Q Altered <br /> (�P$ Latitude I• <br /> __O Q Inactive 0 Truck Q Hauler Q Indoor <br /> Longitude - ( Q Planned ®OTR Q End-Use Q Container <br /> I <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 0 Other I afD fie2e I& f <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFOR--EIMENT STATUS <br /> - - -- - <br /> V A ULING 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/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX 7 <br /> 0 O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: §. <br /> Comments Asxl ,�y�sLComments /�i3si— Y14+7 � 7�tP L✓`zJ <br /> 300 0-f A'lr-. e 62--t X-110 yiW4,111. <br /> Inspection Form Included:Q <br /> y/s, <br /> Comments Include <br /> uslne R s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> � E X A M P 'L E' 1 '2. 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />