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092.10040286 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> WINFID4 State of California <br /> Callfomia awo Integrated C[W^ Waste B 181 eManag Management Board w 04,104) Survey Form - Page 1 I1 108806 2 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' g 111316 7 ® Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y` _ O CHP Q CIWMB O Complaint Q.Educational Visit Q Other <br /> Business or Facility Name p Inspected By Inspector <br /> Ph cal A — D rleQrraY <br /> Ph cal A ress <br /> L_6-7g Gn � �a,� c - <br /> Street <br /> Inspection Date <br /> L <br /> City GState ZIP Cc de Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> ®.PM 0 ® PM <br /> _7770 <br /> _ - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> f ! f ®Active ® Passenger ® Generator ® Outdoor <br /> ! O Closed O Altered <br /> GPS Latitude ,! O Hauler .O Indoor <br /> - - - - - - Inactive_ 0 Truck <br /> Longitude - , i O Q End-Use Q Container <br /> g I I I O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader- Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture 0 Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RENEOREEMENi STATUS <br /> V A HAULINAN01191150M.MESUREQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O 1 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <br /> O 0 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!C-IWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 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 /> 1D dot Im ci <br /> i <br /> Inspection Form Included: O <br /> Comments Included: Q <br /> X77 df ob�-Y6 -7 <br /> Busine s ep's nature Phone Number 1 s S' nat a Phone Number <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: MA 62081 <br /> dXiMP 'LE 1 ,23 <br /> White Cop CIWM Yellow Copy Operator Pink Copy:LEA ® . <br /> I <br />