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08206040084 <br /> ■ �',;r_ Waste Tire. Survey-& Inspection Report .Inspection Report Number ■ <br /> 8tateer California Survey Form - Pagel 1 1 - 10 7 9 2 8 1 <br /> CIWMB 181(New OII04) <br /> Califemla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - _T2 <br /> /� lInspection Type (Fill one) <br /> Site Suffix: ! o 7 T57 Routine Q Re-inspection Q Referral Q Observation <br /> Local —{- If Referral,choose referral type(Fill one) <br /> Identifier: ^/ 1 O 'er ^/ I Q CHP Q CIWMB Q Complaint Q..Educaflonal Visit Q Other <br /> Business or Facility Name --- <br /> Inspected By Inspector <br /> Physical Address 1101 L.J <br /> 9 9 I --- --- <br /> Street <br /> JSra� ^ , �c�i Inspection Date Sd <br /> City t p State Zip Code Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> FU 0 PM FT� 0 PM <br /> — <br /> 6 - —= -- 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) ; I e 9 h <br /> I. Active i Passenger •Generator - 0.Outdoor <br /> IO Q Closed 0 Altered <br /> GPS Latitude W, Q Hauler Q Indoor <br /> O Q Inactive_ 0 Truck <br /> Longitude - I—J 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 /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber A <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 Date m m / m <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 Ior NOV or EXT) <br /> O O --- ------ <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 Referted/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 Compliance - No violations <br /> Q Q 1 Other: § <br /> Comments <br /> T�vc._A_ <br /> Li <br /> Inspection Form Included:Q 209 <br /> Comments Included:Q 44b 9Ile <br /> �3 <br /> ss ep's Signature_ Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C• reef: ncorrect: 62081 <br /> ■ E X k M L 1 2 3 <br /> White C y:CI Yellow Copy:Operator Pink Copy LEA ■ <br />