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08234040042 <br /> == Waste Tire Survey & Inspection Report inspection Report Number <br /> ee¢�_ T i . <br /> Gi State of California I 1 — 1088171 <br /> CIWMB 181(Now 04!04) . <br /> Califamia Integrated Waste Management Board Survey Form --Page. 1 <br /> Part A-Surve ' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 ,/ O / Inspection Type (Fill one) <br /> Site Suffix: 7 Routine Re-inspection Referral <br /> 0 Q P Q 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 L� Inspected By Inspector <br /> Physical AddresswauxA <br /> v ' v <br /> Street <br /> Inspection Date <br /> L <br /> City L✓/r,V State 7ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM' <br /> J0 PM �'� QPM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 100 Closed Q Altered <br /> GPS Latitude I �O <br /> i Q Hauler Q Indoor <br /> '— �_,-_ I —_—_ 0 Inactive Q Truck <br /> --------- - - __- - <br /> ILongitude - Q Planned Q OTR Q End-Use Q.Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 i Other � �nt ons <br /> J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING 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. Compliance 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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1.-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for NOV or EXTJ <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 1 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 /> CommentsQ� <br /> A-&/ <br /> -Ad—Ale <br /> I 4�(A T7fI- (���yH,�..rayf �ZaG'�' Q OO/�— 470 cV �s+/f �•� <br /> _1�J_o�e�f`✓_��TP.L.� � <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business R Signature Phone Number Inspectors Signature Phone Number. <br /> INSTRUCTIONS ON BACK Corre Ime0 re 62081 <br /> E x A M P 'L E 1'2 3 <br /> ■ White y:CIW' Yellow Copy:Operator Pink Copy:LFJ1 ® ■ <br /> i <br />