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a <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> Stateof181(Nrnia SurveyForm - Page 1 1 7 - 10 7282 0 <br /> CIWMB 191(New gMOb) <br /> eallfomla Integrated Waste Management Board L� <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �"^j' 8 3 D 1p - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ,L If Referral,choose referral type(Fill one) <br /> Identifier. CSNa h n _ O CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> n Inspected By Inspector <br /> I UCDnS �(.�� �tr di•C�. I Q / <br /> Physical AddressLA-4,4/ N <br /> Street <br /> Inspection Date <br /> /-�_ _ G9 9s1731 I <br /> City G� �D <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> MOPM O PM <br /> � Operational Status"Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE).; I I A //., (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) .. <br /> f ( I i Active Passenger 19 Generator 0 Outdoor. <br /> I I 1 I <br /> Latitude I I J.�1�_ 10 Q Closed Q Altered <br /> GP$ (_J_ { Q Hauler Q Indoor <br /> O Q In Truck <br /> Longitude - _1� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply):=.M <br /> --- <br /> Q New Tire Dealer *Auto Repair Q Trucking Fleet Q Govemment 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST RE-0 IREMENMS Notice Of Violation Q Extension <br /> Q 0 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§16459 -Responsible Entitles Complying with Manifesting Requirements Date m / III / El <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 EXT) <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/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 Other: §, <br /> Comments Du�inG—tolS � vests <br /> a lrr is_D�C�14 G_�s_ AAD <br /> Inspection Form Included:Q <br /> Comments Included:Q � -- �6� (6�3 <br /> Busln s Re s goal lure Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ore neo eel: E X a Mh P L E I 1 2 3 <br /> ■ White opy.CIWM Yellow Copy:Operator Pink Copy LEA ® ■ <br />