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07312040439 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateofCalifornia Survey-Form - Page 1 1 6 - 10 7 3 5 6 1 <br /> CIWMB 181 Waste <br /> California Intagreted Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ( TPID- - Inspection Type (Fill one) <br /> Site Suffix: F�3 Q 1 13 Z ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �n-.I_ � If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB O Complaint' Q Educational Visit. 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> IPhysical~Address <br /> � �o�-✓tip- <br /> I ,�y_/r_��9td G� I <br /> Street <br /> Inspection Date <br /> City— � St tS_53 Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m'm 0 PM 'm ®PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) i 1 I of; <br /> 10 Active 19 Passenger 0 Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> - GPS Latitude 0 Hauler ®Indoor <br /> J._ O__ QInactive 0Truck <br /> l I -- I � <br /> Longitude I I- — L Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply)' <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Other: § <br /> Comments <br /> - R�.w.ksuc�MS��-un o�. '�� cb �-• ��ss=,�Y�u�r1m_r___l��<<cS <br /> cTA-5 <br /> Inspection Form Included:O <br /> Comments Included:0 <br /> !Buslnless e�atur . one Number Inspector's Signature Phone�4 Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK rrect: correct: &P EXAM P.L E 11 2 3 <br /> ■ Whit opy:CIW Yellow Copy Operator Pink Copy LEA ® ■ <br /> l 1 <br />