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[73i84G4t71�5y <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CWMB 181CaliforniaNSurvey Form - Page 1 _ 11 - 1 0 7 9 2 9 8 <br /> CMIMB tet(Naw oaoa) <br /> Catifomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> f Site Suffix: 1 I q '& <br /> Routine Q Re-inspection. Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L �S9r�r� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic4alC,�dr . doss� ;als_z✓_�_.� 3 9' - 1 D l Lf�u.� <br /> 3�3o s. Hwy �9 I <br /> Street <br /> Sj, G 952 � Inspection Date <br /> rT G <br /> City State ZIP Coe Time In Time Out <br /> Business Rep Title JOAM O AM <br /> JO PM 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> f ° 0 Active is Passenger O.Generator Q Outdoor <br /> Latitude D Q Closed Q Altered <br /> GP.S Q Hauler. Q indoor <br /> O Q inactive Q Truck <br /> Longitude — i I I I 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 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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O 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 / FU <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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMS 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: § 1 <br /> Comments %ug��16�tr�ipy�f ON i7 q �••�,.t / /LO►Jinlq <br /> Ct_s 51 a� �«,., !r-�r.'�� __ _ Ic - <br /> �r'r,Gd-._�a ✓r',�al•t-ov+3 Or C.vt_ta-.t,KS Noi"Ee� <br /> Inspection Form Included:Q <br /> Comments Included:Q�6usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Co ect o I correct: (6) g I E 11 X A JIM I P E L S 2 3 62081 <br /> ■ While Cop:CIWM Yellow Copy.Operator Pink Copy:LEA ® ■ <br />