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09182050018 <br /> �= Waste Tire Survey & Inspection Report Inspection Report Number <br /> eae_ <br /> State of California <br /> CIWMB IBI(Ne W04) Survey Form - Page 11108424 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —_T IS <br /> I Inspection Type (Fill one) <br /> Site Suffix: L/JaJ $ y- q FO I j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ['_Y_LY1 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: tJ\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I A.( 1omCLS-Tnx t� •Tv. j <br /> Physical Address - ` Q , 4 � �.L�` <br /> II <br /> J-9555--k- <br /> Street <br /> Inspection Date / [OKI <br /> I�rn pyo (24_ _`1 Qej <br /> City State ['P coi4e Time In Time Out <br /> Business Rep Title <br /> ` QAM . G / Q AM <br /> - - — - - - PM " z I (a PM <br /> -V 0 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) a G <br /> t f ®Active Q Passenger ® Generator ®Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 Inactive ®Truck <br /> Longitude - I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <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 <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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f 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 <br /> � Cor_nna _ P <br /> Inspection Form Included. 0 <br /> Comments Included: ® <br /> siness Rep's Sig ture Phone Number ns a or's ign ture Phone Number <br /> INSTRUCTIONS ON BACK C rect: Incorrect: ( 62081 <br /> EXR !►gP 'L E� 1 ;2 3 <br /> White opy:CI Yellow Copy:Operator Pink Copy:LEA <br />