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09217040236 <br /> Waste-Tire Survey & Inspection Report Inspection Report Number <br /> 99i State of CaliforniaClW <br /> California <br /> Integrated MB181(Neste w 04104) <br /> Board Survey Form - Pagel 1 � I 1 � 108847 <br /> 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L �11 Inspection Type (Fill one) <br /> Site <br /> Slte Suffix: ` I Q� O l ® Routine Re-inspection Referral <br /> 0 P 0 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Xqd'N'YA 6007 <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name a Inspected By Inspector <br /> L--�imM_N_q S Case c� /_� S I [�E <br /> _ <br /> Physical Addres <br /> Street <br /> Inspection Date O <br /> city ` /F— Time In Time Out <br /> City State 7_lP Comae <br /> Business Rep Title 0A M h Q AM <br /> -� ,V_\(a�Y.V�Qy�(-- - -y�V�• = • - - L I� I - �I ® PM � ja I ® PM <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 /> •Active ® Passenger ®Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> _O 0 Inactive 0 Truck <br /> Longitude - 0 Planned D OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 <br /> f iolation <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice OV0 Extension <br /> 0 0 PRC§42.953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXV <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 1010 Other: § <br /> Comments � r A.00��7b � -- <br /> Inspection Form Included: 0 <br /> Comments Included: 0 71-1/ <br /> B iness ep' nature Phone Number Inspe or Signa re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C•rrect: Incorrect: tc X A I:'P L 1 2 3 <br /> White C y:CIW Yellow Copy:Operator Pink Copy:LEA <br />