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09105040002 <br /> �_�,_ Waste Tire Survey & Inspection Report Inspection Report Number <br /> state�r„ CFWM 181ICalifomia Survey Form Page 1 I 1 10 8 8 0 4 2 <br /> CM/MB 181 stew nage Y <br /> California Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: $ I Q Routine ®Re-inspection Q Referral Q Observation <br /> Local 1 C N Referral,choose referral type(Fill one) <br /> Identifier: S4 n Jba<{Lu n o y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Lo oq �. CcSf�, - L_� <br /> ICA,4 i �� <br /> Physical Address V <br /> - <br /> Strset m <br /> ` �� ICA ()15„"- Inspection Date � � I= / [oj�](-J}t�L —s(3te`Z�pvlovny�V Time In Time OutJ <br /> Business Rep Title i IOAM u <br /> I io I� OAM <br /> �O�.II .• �41'k' rnU(1a v `- i O•PM 'I.-. ®PM <br /> -- - -- - — - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) - (Fill.all that appy) (Fill all that apply) (Fill all that apply) <br /> r 1 0 Active II*Passenger IS Generator -'Outdoor <br /> O Q Closed Altered <br /> GPS Latitude , Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned S 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 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 /> r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other TL <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS`-1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 I 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 Q Other: §. _ _ �1 <br /> Comments ',nS-p`vt-1-Of% —a��W <1�1���Q <br /> < <br /> �t.n <br /> - :, (_ ,J ! �( <br /> ►•,4�—�— 1 ` `, ��d�t 65111 C ( i oue.—-C�_Zxi�T e <br /> ter 0 C r� n scQ s rti s <br /> Z. <br /> Inspection Form Included: n <br /> Comments Included:Q <br /> Business ep's SjgtLature Phone Number Inspector's Signature ���/// Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rect: I correct:X(% 0 X A M P L E 1 2 3 <br /> ■ White CopV Yellow Copy.Operator Plnk Copy LEA ® ■ <br />