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FORM NO.M-105547-CIWMB M12 19 9876 543 21 <br /> =E , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 1 6 - 1 0 1" 9 4 0 2 <br /> Californiala Integrated WasttManage <br /> 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: 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `�c�Lv� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> 1203+0�Iruvvl� Vv�ct �Jr .- <br /> C,,^^ Inspection Date Z / 7 / U 7 <br /> Time In Time Out <br /> Business Rep Title ®AM ® AM <br /> QPM -- — - QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator <br /> '� � 9 ® 0 Outdoor <br /> O 0 Closed 0 Altered GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> - <br /> Business Type (Fill all that apply) ( <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government <br /> 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 (9 Other ti '�Yrl <br /> Inspection of Waste Tire DealerGenerator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> Part , <br /> V I A 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 <br /> 0 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 EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> . ...... ----- _ ----------------------- <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 )K 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators # In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> J IDS :H)= Luca 4V dI�C7;C_ _ <br /> ��— >z �T X13 3 -�c le _4Q.4cx• �1� ��i ,r11 s !zl, .4j.:V TM— Joe .�.r►�. .-1 , <br /> *74 <br /> Inspection Form Included: 0 •. � <br /> �,1� v X168—osay <br /> Comments Included: 0 -- _ <br /> Business Rep's Slgnatur Phone Number spector's Signature Phone Number <br /> IA1cTolif%Tinuio nu r�wn . .-I I r l..I .I..I..f. 1. — ---- 62081 <br />