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07312040422 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> ra CfWMB81(NCalifornia Survey Form - Page 1 i l - 1 0 7 3 5 7 0 <br /> CnNMB 187(New 06!06) <br /> Califomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- m Inspection Type (Fill one) <br /> Site Suffix: 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 Inspector <br /> I U`.YUsa P <br /> —Inl_tl:u_ I <br /> Physical Address 3 �/. - F/T-o / <br /> i Street <br /> Inspection Date Z S O <br /> �ify �tQiJ+N• C �}} State <br /> t�6 ZIP Code I Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> i4Nn6u fTVQ�05 m•MOPM m ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f I t (7S <br /> l' ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude I I O Q Closed Q Altered <br /> GPS —J J•L — 1—L� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> I ' <br /> Longitude — Ir— I I Q Planned 0 OTR Q End-Use Q Container <br /> -- J—— <br /> 1 I <br /> Business Type (Fill all that appy) <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®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 Notice Of Violation Q Extension <br /> Q Q <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 <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(or NOV or E-f <br /> Q X 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 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 )1$ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> �,:.T%xs_�=mss t� /_tu��✓-±cul—oc%�S�rL�t-j— <br /> — iY�s C�rtd GTL .vLacts. gt/w�ckl.� wr�v <br /> Inspection Form Included:Q h <br /> Comments Included:Q <br /> Ssrness Rep' nat Phone Number nsp9nature Phone Number <br /> INSTRUCTIONS ON BACK •o ect ncorrect: 62081 <br /> EXA'AgP'LE 1112131 <br /> ■ While opy.CI Yellow Copy:Operator Pink Copy LEA ® ■ <br />