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08129040856 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> roe — <br /> �° StaleolCallfomle Survey Form - Page 1 1 8 - 1 0 7 2 8 2� <br /> CIWMB 181(Now 04104) <br /> Celifomia Intograted Waste Management aoard <br /> Part A-Survey BLUE OR BLACK_INK PEN_ <br /> Business Profile _ Inspection Details <br /> TI - [= <br /> / / I D / Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identlfler. � O, � / �_.A Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name �tV Inspected By Inspector <br /> , [�T - <br /> Physicalss <br /> L__43 N_. ,ar,� 67— <br /> Street 15 8 <br /> _ 6A J5-3� Inspection Date <br /> 6 State gP LOUe Time In Time Out <br /> Business Rep Title / O AM Q AM <br /> m•m 0 PM m'm O PM <br /> ' Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(W hole/PTE) I�j (Fill one only) (Fill all that apply) (Fill.all that apply) (Fill all that apply) <br /> r• f `� 0 Active Passenger •Generator 0 Outdoor <br /> Latitude I l -IO Q Closed Q Altered. <br /> GPS -L!�•I __�� Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Ii -J I I - I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) L <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 /> 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 orEXT) <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/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 10 1 Other: § // <br /> Comments br fh 5 S— 1 dyr 7jr1 d Q. %)rr�s Tr4 A <br /> use ,J"as lie.'. r_ea-:sT�A_J %A) L tr/'v-,- 1jCa✓4 _ `Y,�tf � <br /> —ICs f kJ o,�• N� Vr a�4t i B+1S(/d2 601 A t Ne L4-p <br /> Inspection Form Included:Q <br /> Comments Included:Q — <br /> Business Rep's Signature Phone Number Inspectors Ignature- Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrec - incorrect: (� I;- X a Ab P L e 1112131 <br /> ■ White Cop•CIW M Yellow Copy.Operator Pink Copy:LEA ® ■ <br />