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08206040092 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> �r StateCalifornia Survey Form-- Page 1 1 6 - 1 0 7 9 2 7 8 <br /> CIWMB 181(New 06/00) - <br /> Califomia Integrated Waste Management Board - <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> � TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q ObservationVG� <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . 5An! J��•�•�/ 6l`4.P^1%!a- _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical-Add ss ' i�N MGyC7r I - F M01 <br /> Street <br /> Inspection Date D S <br /> City State ZIP Cede Time In Time Out <br /> Business Rep Title OAM Q AM <br /> li—I 0 PM F7 0 P <br /> Operational Status Tire Type Business Role. Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r: ! r 1319 <br /> 0 Active 0 Passenger 10 Generator 0 Outdoor <br /> I� I II 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - Q Inactive Q Truck <br /> Longitude - ! Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> 0 New Tire Dealer •Auto Repair Q Trucking Fleet Q Government . Q Retreader Q Dismantler Q Tire Derived Fuel <br /> lb 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 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 <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 for NOV or EX7J <br /> 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 D` L�� /'��`�'vJ J/iT�- OY�. /fL�� �r[LtilJSL ,����/N� L.Ja-O � NO 1ncp.• <br /> f/iet,�1�. �C .✓r /a�►eYr1 0r </ r c s <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Re Ignature Phone Number . Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK t orre Incorrect: ly X A M P L E` 11 2 3 62081 <br /> . Whit C py CIW Yellow Copy:Operator Pink Copy.LEA ® ■ <br />