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07312040438 <br /> Waste Tire Survey & Inspection Report Inspection Report Number M <br /> StaCalMomia <br /> CIWMte8of 161(New04104) Survey Form- Page -1 18 - 10 7 3 5 71 <br /> califomla Integrated Waste Management Boatd. <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- / Z J s ' Inspection Type (Fill one) <br /> Site Suffix: C ®Routine Q Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose.referral type(Fill one) <br /> Identifier: ^�&Jv"V' cff" yTCHP. O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address' . . I 3 '� = L— <br /> I 4 Street 3 I_E .—M'.'t;r o c c, <br /> Inspection Date <br /> I CA <br /> ity State Zip ode I Time In Time Out <br /> [I] [= <br /> Business Rep Title Q AM Q AM <br /> •PM <br /> -_� k._fv .f1 Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)-. <br /> ®Active Q Passenger ®Generator O Outdoor <br /> I O O Closed <br /> GPS .Latitude Q Altered O Hauler Q Indoor <br /> O Inactive ®Truck <br /> Longitude – �I I �I ( I �O 0 Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O 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 <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m / <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 1 Other: § <br /> Comments <br /> x tnc�3�� Eir.. -�-t,,,,c o�a�-c.• �L`f_t�'cd��up�v fS <br /> --U1J�s-i3,�V11w�-I�cc- �D_'I—v_��_t���-t.._�Jslt_��s—r-uta✓-�t>a��iPrnx <br /> Inspection Form Included:O . y <br /> Comments lncluded:Q —AA AA <br /> _ �–Oto23 <br /> Business ep' ign Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAC Correct: Incorrect: ( E X a M P. L E[ 111213 62081 <br /> ■ hite Copy.C Yellow Copy Operator Pink Copy.LEA ® ■ <br />