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07312040437 <br /> irr. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CFWMCalifornia <br /> lSurvEmey Form - Page 1 1 1 0 7 3 512 <br /> CIWMB 18i 181((New Ortel) <br /> Callromla 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: I / y 9 / 1 - <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say, - rse piyvy� C�un.(ry� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f {� Inspected By Inspector <br /> Physical Address l 11 7raMs P6r+ h�or I 3 y _ / O / L ,,� f,ut i <br /> I 2ysy_r_-t ,�o��rte. <br /> Street <br /> Inspection Date <br /> I S to_t tc t c� 9_S 10 S' I <br /> City State Z1P code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> M�`— ®PM ELI ®PM <br /> Operational Status. Tire Type .Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i � i <br /> 13 I ®Active Q Passenger *Generator Q Outdoor <br /> Latitude I IO Q Closed Q Altered <br /> GP$ I-L__I-- J—l-._ Q Hauler Q Indoor <br /> -- O Q Inactive ®Truck <br /> Longitude - 1.1U J-L I -i-� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V =HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance 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 for NOV or EX l7 <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 Refer►ed/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 C-ompliance - No Vi lotions <br /> Q Q Other: § <br /> Comments <br /> a� <br /> �+� ���¢.1_s.—�/SLS✓_r�6�Gr�ars._/ /_T��X.���n.ce.�r <br /> /fid—frxraLes�Scfh�— ��/�✓�'o_ls�h`ur�r a <br /> Inspection Form Included:Q <br /> Comments Included:Q �6 �6 <br /> Business Rep's na re. Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �rirectWjl��� X A M P L E 1 :2 3WhiteYellow Copy.Operator Pink Copy.LFI\ ® ■ <br />