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03259es®es3 <br /> =gig .Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr State of California <br /> C1wMB 181(New gSurvey Form - Page 1- I 1 - 11412 3 8 <br /> ' CaliforniaalifoIntegrated WasttManagement <br /> Waste Managee ment Board ' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 15 1 d; -1 q - I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �. ---� If Referral,choose referral type(Fill one) <br /> Identifier: I Sun —, y`yj-�,U�n_ l". Q CHP Q CIWMB Q•Complaint Q Educational Visit Q Other <br /> Bust ss or FacilityName ` �-J <br /> Inspected By Inspector <br /> (��-- LO-1-i-41-cs-------- <br /> Physi a� I Address I0 L_L_�_j L& b � � <br /> L V <br /> Street I L_VJ��� <br /> Inspection Date <br /> __vn C_1 - Q-moo <br /> cyly -- Jtflte ZIP Code I Time In _ Time Out _ <br /> Business Rep Title ( 10AM �� • 0 AM <br /> 1 "� <br /> 3_1 —O—L�* PM I [010 <br /> �PM <br /> ZVI- <br /> Operational Status Tire Type'- Business Role- Storage-Type <br /> Tire Count(Whole/PTE). I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill-all that.apply) <br /> f ' •Active Q Passenger ® Generator ®Outdoor <br /> r—' - -- O Q Closed Q Altered <br /> Latitude <br /> L - - <br /> —_ J Q Hauler Q Indoor <br /> i0 Q Inactive Q Truck <br /> Q Planned � OTR <br /> Longitude Q End-Use Q Container <br /> �, I l � .� � I <br /> Business Type (Fill all that apply) Fp'l�ll <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 p Shredder ID Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use-Facility- aENFORCEMENTSTATUS �;` �.':'>. <br /> Y ,. .. <br /> 'Notice Of?t a4 9e S•.:a iF 1 �:,' IY'rea#- `�>3•t S'�r ai '�a 94Vtolation :l J�p.•4!'- •;"? <br /> V A ,HAULING ANMmANIFEST REQUIREMENTS <br /> ® Q-Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires * .�... + <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Deadline, <br /> Q Q PRC§42956-Registration/Decal in Vehicle ; r <br /> 014 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements �Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIW MB p<., <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days W- (RegwrndfOf-NOVor.DX7) s1 <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/C WMB Enforcement, <br /> Q Q 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> § Y q � t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a . P <br /> Q Q Other: § Q,�n l:ompI ance No olations <br /> Vi <br /> Y • .a. . <br /> Comments tj . <br /> I%4 - ��c uIAIIAMWulS-A66k 6 �_r_� - <br /> �� t` P <br /> (A.A5 -o r -Q-5, <br /> Inspection Form Included: QIsl <br /> Comments Included: 1- <br /> u ' ess p' ig Phone Number Ins tors Si nature `•' Phone Number <br /> s t k <br /> 3 62081 <br /> L <br /> INSTRUCTIONS ON BACK o sect In correct C Ej[X R jM P E 1 -2 <br /> White Cop CIW Yellow Copy.Operator Pink Copy.LEA <br />