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_08066040044 <br /> « , Waste Tire Survey & Inspection Report ,, Inspection Report NumberState <br /> rri CIWM l$ll(Now Survey Form -� Page`1 16 1 0 l 9 4 5 1 <br /> CIWMB 181(New OM04) <br /> Callfomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I L ^' O I Inspection Type (Fill one) <br /> Site Suffix:.. TV (n,,,,'( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local al,c <br /> `� V -E�Pr� If Referral, referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Inspected By inspector <br /> mk�f� ?) <br /> - TO I L � , <br /> Physical Address <br /> LLtl-7d'f T�14e Vr": <br /> Street ,-\\ / q <br /> <`. N C,� L��-1< I Inspection Date O ' ✓V l D t.J <br /> City State ZIP Code Time In Time Out <br /> Business U Rep <br /> C Title O AM Q AM <br /> D2NN1 J �arl �erJ a/_,F6 h1d'( ..� Cm m®PM- Lu <br /> m ®PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count.(WhoIe/PTE) I i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ®Active Q Passenger ®Generator Q Outdoor. <br /> Q Closed Q Altered . <br /> GPS Latitude � Q Hauler ®Indoor-` <br /> O Q Inactive ®Truck <br /> Longitude - (� L� 7 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J i <br /> Q New Tire Dealer Q Auto Repair 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENit STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violatlan 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 j <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 for NOV or FXT) <br /> Q Q 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 Referred/C-IWMB 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 Other: § j <br /> Comments <br /> \ I Y a <br /> O A "' fiv'2 IN Oil') I fe tr_ �fe_ v e p� <br /> k �6 i 6 e 6Y <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> �BuslnetM;s signal Phone Number. nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XjA M p `� �' Z 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator PinkCopy:LEA <br />