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08206040147 <br /> nr <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> °Q 8tateefCallfomla Survey Form - Page 1 12 - 1 0 l g 2 6 6 <br /> ChVMB 181(New 841061 <br /> California Integrated Waate Management Boerd <br /> 'art A-Survey _ BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> I inspection Type (Fill one) <br /> Site <br /> Sufx: 0 <br /> I0 I /01�J6� 0 Routine <br /> Q Re-inspection Q Referral Q Observation <br /> Local I : ����, If Referral,choose referral type(Fill one) <br /> Identifier. L � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bustne ar Facility Name Inspected By Inspector <br /> a/u <br /> Physics Address / Y / - I D ! I L I � <br /> 1 Zy(s0 Daus SG 4v c — <br /> _ Street <br /> l n Inspection Date <br /> F-W <br /> City Statle Time I / r� ►7 / O <br /> Time Outt - <br /> Business Rep Title AM AM <br /> m <br /> FOAM m'm 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> ^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ` <br /> �' I � � .Active Q Passenger 40 Generator 40 Outdoor <br /> 1 mO Q Closed Q Altered. <br /> GPS Latitude , I I I I Q Hauler Q Indoor <br /> Q Inactive Truck <br /> Longitude - I--� I I I 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 I i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCE i <br /> p y MENTiS1T/AYTiUS <br /> V)MAIdtHAULING1l'AtNUjMANIF <br /> Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension <br /> .Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 EX7 <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/C^IWMB 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 Q Other: §, <br /> Comments j� l <br /> /StT�r�•N C .�IV e.f�r_(jv� OLr /l+rc�. GY ct�i_ _ %�_. `1�t✓,it <br /> (J 67✓0 A)o <br /> / e i <br /> ( O-7 CChInspection Form Form Included:QI3y� 1)et�t,[ (7Z q) <br /> Comments Included:Q / —" "_—` --- - '�A <br /> mess R ig ture Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK jneorrect: I EjXj AjMj P R L I E k I l G.z 13 I 62081 <br /> ■ White py.CIW Yellow Copy Operator Pink Copy.LEA ® ■ <br /> 1 <br />