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07312040403 <br /> ■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ora <br /> State <br /> eo181(Califomla Survey Form- Page 1 1 1 3 . 10 7 3 3 3 6 <br /> CIWMB 1B1(New 04!041 <br /> Caliromla Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (,� Inspection Type (Fill one) <br /> Site Suffix: .I F I q6 [a[a 0 I ®Routine Q Re-inspection Q Referral Q Observation } <br /> LocalF�� <br /> T If Referral,choose referral type(Fill one) <br /> Identifier: �./o� Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> } i Q T ve-S 3 <br /> Physical .ess I 0_1 - Mo / �T '(u_ ffya� <br /> Street <br /> 6� l I �a q� / O I Inspection Date <br /> l l^i�WJ_'7"�,L't <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 Am 0 AM <br /> EEI: <br /> m O PM 11-1: <br /> m O PM <br /> ----- — t_ -- --_ —J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ; ! <br /> t ° 1 O Q Active Q Passenger Q Generator Q Outdoor <br /> I 10 ®Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> .—�J Q Inactive Q Truck <br /> Longitude – I I, I Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 111 JJJ _ <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 Q Other <br /> Part B--Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 'RCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 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 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 1)� f Wu SAam o f�� S Q� <br /> I_ tS -FD✓ � Ce- <br /> - i <br /> Inspection Form Included:Q ^�� �� <br /> Comments Included:O JL` — <br /> Busi es Rep's Signature Phone Number a tors nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK CorrecQO Incorrect: E X A hA P:L E 1 2 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> I <br />