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08038040317 <br /> MWaste Tire Survey & Inspection Report lnspection:Report'Number. <br /> etWMB1ate of 1(No aSurveyForm Page 1 12 - 10 10 83 3 <br /> CIvvMB t01(New 04!04) <br /> Calliornia Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Y , Inspection Type (Fill one) <br /> Site Suffix: 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local ,,ff If Referral,choose referral type(Fill one) <br /> Identifier: �L7i'> 0 CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> —Name Inspected By Inspector <br /> PhySiCal Address YK <br /> =0 / <br /> �-7/•J�Y'��/ <br /> Street <br /> Inspection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> IBusiness Rep Title m JOA ryl m m O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r r`/ Q,� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �L 40 Active is Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - FTE- Q Planned Q OTR Q End-Use Q Container <br /> ' Business Type (Fill all that apply) <br /> Q New Tire Dealer i Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body le Car Dealer Q Collection Q Crumb Rubber <br /> 41 Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFig.R6EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance 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(a)(b)(c)-Tire Program ID Number from CIWM8 <br /> Q Q 14 CCR_§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> IQ Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> O 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 1 Other: § <br /> Comments �-.1� �2 � may',�, �/A 1_ L��l� •�✓i� fc�g' <br /> Inspection Form Included:Q <br /> Comments Included:Q — - /� 7. 4w, <br /> Business Rep's Signature Phon umber Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct IncorrectEX 'L E 111,2131 62081 <br /> �t <br /> White Copy CIWMB Yellow Copy.Operator Pinkk l <br /> Copy:LEA <br />