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08234040040 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State Or California Survey Form - Page 1 I1 - '1088149 <br /> r CIWMB 181(New alasl y ('� <br /> calHomla Integrated 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: 1 3 �- [31 (/ •Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'jAy� V`�4q w'r•/ (�V�y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !/ Inspected By Inspector <br /> Physical Address 3 9 - O ,�.s.� <br /> X2202 o_nf_�t/1�+�.�Ae�.rh+.ue_�►,e I — <br /> Street Inspection Date <br /> Cy ZIP Code- <br /> 'I Time In mI: 0Time Out <br /> Business Rep Title [:IjPM <br /> :meOAM <br /> lO <br /> Operational Status Tire Type Business Role <br /> Type <br /> Tire Count(Whole/PTE)• f l /J (Fill one only) (F.ill-all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 f� 0 Active Q Passenger 0 Generator Q Outdoor <br /> f Q Closed Q Altered <br /> GPS Latitude <br /> I I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - i I, Q Planned •OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Is Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFOIZC-_EMEN1T S1TATUS <br /> Y i A i HAULING AND MANIFEST REQUIREMENTS <br /> Q i Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires �I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance 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/or 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 I 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 Other: § <br /> Comments <br /> rit,_.Qw.- —G_tF_C.r— !/L.O-�— sem_✓_��Fl.�/ /�*ta%+ ,/—�pS�L�(. /!'t� <br /> _Acz___✓✓,''o_L�ft aresD ^cap+s-4J/s_n_D• l�/� <br /> Inspection Form Included:Q �f,Q <br /> v O �'rn[t•_� <br /> Comments Included:Q — ` <br /> Bust ess Re s Sl tur Phon Num 1 Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BA K 5rrewcf�! Incorrect: E X A M PL E 1 2 3 62081 <br /> White Yellow Copy:Operator Pink Copy:LEA ® ■ <br />