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08184040093 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> u CIWMB 1rate of WMB1a1(New <br /> 04104)elitemla Survey Form - Page - 10 7 3 4 4 9 <br /> C <br /> California Integrated Waste Management1 L I 9 <br /> Board — <br /> Part A-SurveBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I CSU6; 0 Inspection Type (Fill one) <br /> Site Suffix: i � - •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit. Q Other <br /> Business or Facility Name W U Inspected By Inspector <br /> Physical Address . [�� - F/ <br /> I, BDP 0e4 __j <br /> Street / <br /> Inspection Date <br /> City O State ZIP Code Time In Time Out _ <br /> Business Rep Title O0 AM 0 AM <br /> PM C�'C� Q PM <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 /> t tto Q Active Q Passenger Q Generator Q Outdoor <br /> j 'O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> ' 0 Inactive Q Truck <br /> _----0 <br /> Q End-Use Q Container <br /> Longitude - i i Q Planned Q OTR <br /> i <br /> Business Type (Fill all that apply) <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 40 Other L g -/ ..O <br /> Part B-Inspection of Waste Tire Dealer,Generator,.Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 Date <br /> M / m / m <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 1 Q 1 Other: § <br /> Comments Ic <br /> i h�agf�7^T/tea �� �. �¢aa� %' 7! .—%n1 a_ Jy.vY 7'PSD✓ ' <br /> Inspection Form Included:.Q 7�` aQ '�^yJ �d9 <br /> Comments Included:Q- \ - WL3o 6�L " - <br /> u mess Rep's.Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect. )ncorrect: 0 0 X A E 1 :Z 62081 <br /> ■ White Copy:CIWM Yellow Copy:Operator Pink Copy LEA ® ■ <br /> I __J <br />