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08087040003 <br /> ■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> crr. <br /> �r <br /> State WMB181(Nrnle -- Survey-Form.- Page•1- 19 - � 0. 0 8 6 4 <br /> CIWMB 181(New nooa ' <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 2 ] - [�JE Inspection Type (Fill one) <br /> Site Suffix: I y J 7 e( /�7 Routine Q Re-inspection Q Referral Q Observation <br /> Local (/� If Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CIWMB, Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ^ Inspected By Inspec or <br /> , /1?c/L,n /rte. �r �•�� ' 3 9' - F/I I <br /> Physical Address <br /> V <br /> Street <br /> / Inspection Date <br /> City (State y ZIP Code Time In Time Out <br /> Business Rep TitlemO AM O AM <br /> �L! 14_ i /Q,�a M0 PM m 'm 0 P <br /> I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I / D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ' GPS Latitude m� Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Fm Q Planned Q 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber p <br /> A-Q Service Station Q Hauler Q Agriculture Q Shredder �Other ���"�-�f <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMEN1T STATUS <br /> Y A HAULING 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs"within 90 days (Required for NOV or EXTJ <br /> Q O - -- — - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 Gompllance - No Violations <br /> Q Q 1 Other: § <br /> Comments Zs¢ ' ,_ __ �//- �p — <br /> itwed -ft_'W or, c V' 4v <br /> Inspection Form Included:Q /J ,p27�pI <br /> Comments Included:Q ���� r�j�, OSY <br /> mess ep's dignatur Phone Number Inspector's Signature Phone Number . <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: fr X A P E 1 :2 3 <br /> ■ White Copy:CIWMB Yellow Copy.Operator - Pink Copy:LEA ® S <br />