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08129041106 <br /> Waste Tire Survey. & Inspection Report Inspection Report Number � <br /> ■ -orr- state of Califomia <br /> CIWMB 181(N..04104) . Survey.Form - Page 1 - I 7 . 10728451 <br /> 1;mja Integrated Waste Management Board <br /> Part Ace Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 I I S 6 O / Inspection Type (Fill one) <br /> Site Suffix: 9 I ®Routine Q Re-inspection Q Referral 00 <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - D /(�/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f/ Inspected By Inspector <br /> i rr. _j <br /> Physical Ad�d/ress [Ell <br /> 2 f p _­ <br /> I Street <br /> IStreet c.J � C4 9gaa51 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m O AM 0 AM <br /> PM m m O PM <br /> Aj- a o r Qh_ L_— .—- <br /> __J,ah_ � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> i I Latitude i _ Q Active Q Passenger Q Generator . Q Outdoor <br /> � ��GPS � O Q Closed Q Altered Q Hauler Q Indoor <br /> O ®Inactive Q Truck <br /> Longitude - 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 /> Q Used Tire Dealer Q Auto Body. Q Car Dealer Q Collection Q Crumb Rubber <br /> p service Station Q Hauler Q Agriculture Q Shredder Q Other I <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 Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data 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/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 1 Q 1 Other: § /- <br /> Comments <br /> iG(1�lQ�l{ __l A& .)G • FR Ci <br /> hUS r �Q � �Lvylyl�� <br /> rl_ e_� ]S.1N0_f���' ftrk C e Pa$SCh r"' <br /> dclucies <br /> ,?_,,,Llc�e4 ai oF�-��Jevtd_o►�s.Jib��rW1,2f, fgur 0, ewe <br /> ' ,RvKj_iP -bird Ole - - ►�i,� <br /> 6na,U Dnac7ivafe I D <br /> Inspection Form Included:Q t� <br /> Comments <br /> Busines Rep's,Signature Phone Number Inspector's Sig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:b Incorrect:mV X R M 62081 P L 1 Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />