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®8129041112 <br /> Waste Tire Survey & Inspection Reportinspection Report Number <br /> State CrWM 181(California Survey Form Page 1 16 - 10 7 915 4 <br /> CIWMB tet(Naw nag4) <br /> California Integrated Waate Management Board <br /> Part A Survev BLUE OR BLACK INK PEN <br /> (Business Profile. Inspection Details <br /> TPID- I I 1315 <br /> � S J � �� 6-1 � I [E/ <br /> Inspection.Type (Fill one) <br /> Site suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — o If Referral,choosereferral type(Fill one) <br /> Identifier: f (�` ("�/� t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "(�/%J Inspected By Inspector <br /> S4X e7b n- _ fv C�� I 9 _ a i <br /> Physical Address ( I I L�Oi. ` #� <br /> n � <br /> /gra -dill,Ha► � <br /> Street <br /> stock-gym Q� q saw I Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep Title Q AM <br /> -�,,^O',� n ' JOAM <br /> 0PM OPM <br /> —� Operational Status Tire Type Business Role Storage Type <br /> �LJ-- — Fill one only) Fill all that a Fill all that apply) Fill all that a <br /> Tire Count(Whole/PTE) �, 3 ( ( apply) ( pp y) ( apply) <br /> r ° t ®Active ®Passenger . 0 Generator 0 Outdoor <br /> -----i_ 10 0 Closed O Altered <br /> GPS Latitude I I 0 Hauler ®Indoor <br /> — -- IO 0 Inactive 0 Truck <br /> _1__— <br /> Longitude — I TI I I I I-1 0 Planned 0 OTR 0 End-Use 1 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> In 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®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 /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 /> 0 0 Other: §. <br /> Comments E,,ki� 1 *_4_S ?DC egg o W I ink w_o1 ' <br /> has t,�t� ln�ac�z1'l .t��t s /1° Jtf"a Sipes <br /> *M <br /> ' --ires �- e 9 or le-s4 <br /> Inspection FormIncluded:01 <br /> Comments Included:0 /r ' Lt <br /> B I s p's Signature Phone Number Inspecto s Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS CK Correct:* Incorrect:X� dIiEii i �iAiP �� �1[213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />