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07312040445 ✓ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ '° StateCrNM 18111or°� Survey Form - Page 1 1 9 . 1 0 7 3 3 2 51 ■ <br /> C1WMB 191 stew oage Y <br /> Catifomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I n n Inspection.Type (Fill one) <br /> Site Suffix: % b Routine Q Re-inspection Q Referral Q Observation <br /> Local L T If Referral,choose referral type(Fill one) <br /> Identifier: LJAin Jp/)Lim Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business orFacility Name Inspected By Inspector <br /> COX <br /> Physical Address <br /> I 5b'7 'Fo <br /> Street <br /> Inspection Date <br /> Vt^ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title , ! 0 AM Q AM <br /> m0 PM m-m O PM <br /> Operational Status TireType Business Role Storage Type <br /> Tire Count(Whole/PTE) 1r/) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i <br /> " ®Active ®Passenger ®Generator Q Outdoor <br /> I I O Q Closed Q Altered <br /> GPS Latitude I I �,�—�--��� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®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 Q Other l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Vlolatien s n <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42.953-Contracts with Registered Waste Tire Haulers. Eompliance 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 (Required 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 I C^IWMB 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 C-ompliance No Violations <br /> Q 1 Q Other: <br /> Comments0 <br /> Ida _Cav�,W" adc Csdl>s .kw1w <br /> 7P(rp(J ICDZo� <br /> fpr wag GTL wtr �cstsy►eWo +Ot - <br /> _hod <br /> Inspection Form Included:Q <br /> Comments Included:Q- � — 9 <br /> usiness fiep's S na re Phone Number Inspe Signature Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjAjP[L1E1 1112131 <br /> 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />