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001: 61.04.004:4. <br /> L=== Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee. <br /> 11 State of California <br /> 11 1088481 <br /> t Survey Form - Page 1 <br /> CIWMB 181 New.04104 j <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I j— 1 3J3 <br /> ' T j j -, Inspection Type (Fill one) <br /> Site Suffix: 11 3 I `1 I LO 4k Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �alf J u+(, I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> � <br /> Business or Facility Name ` 1 <br /> Inspected By Inspector <br /> Seg <br /> Physical Addre9s - 3 <br /> LTJ -�s� <br /> &r)_ 1 <br /> Street <br /> Inspection Date <br /> T— � -�— — -J Time In Time Out <br /> :,ny Stmt irr'Cooe ----- -— — - -- <br /> Business Rep Title I <br /> 1 I$0 AM i i . �- --� *AM <br /> O :O O PM-13 O PM <br /> Ca 4% v, Operational Status Tire Type Business Role Storage Type <br /> I / 4 <br /> Tire Count(Whole/PTE) . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 11L_J <br /> ®Active Q Passenger (1h Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -. O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <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 a Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORC--EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice of Violation <br /> O O Q Extension <br /> 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 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 DCT) <br /> Q O 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 Refe !CIWMB Enforcement <br /> Q 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 C-ompliance - No Violations <br /> Q 1 Q Other: § <br /> Comments �D �_l�lc. 1-��4�-v�C-9•n= W��1�-dam 4•t�rr)1--- --.0-. b_Lu��Gl—Wct��-(_l���l,� <br /> Inspection Form Included: Q T <br /> Comments Included: 0s <br /> Business R 's i lure Phone Number Insp oes Signature Phone Number <br /> INSTRUCTIONS ON BACK ISect: Incorrect: A�E X A P L 1112 3 62081 <br /> White Cop CIWMB Yellow Copy.Operator Pink Copy.LEA <br />