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08129041094 <br /> qoq_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> .1 California <br /> CEWMB 191 stew naSurveyForm - Page 1 1 2 - 10 7 91 4 2 <br /> CIWM <br /> Californiaalintegrated Waste Managege ment Board <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I i I - O I Inspection Type (Fill one) <br /> Site Suffix: 1 I ®Routine Q Re-inspection Q Referral Q Observation <br /> I Local n I If Referral,choose referral type(Fill one) <br /> Identifier: `'-a'f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r 1 L�1 <br /> Inspected By Inspector <br /> Physical Address - I Q I I I I V`_,LrL,� IY ass I <br /> �7 S vf l <br /> Street <br /> -r} _� ' ����i Inspection Date.. <br /> I `T►'A`j(J to l Time In Time Out <br /> City State ZIP Code <br /> Business Rep � tQ/`�1T �p Title 0 AM O AM <br /> /V <br /> V 0 PM 0 PM <br /> " <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) J1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) - <br /> (/ ®Active Q Passenger @ Generator Q Outdoor <br /> GPS O Q Closed Q Altered <br /> Latitude Q Hauler 16 Indoor <br /> I I Ji—JI <br /> L I --1—I_. Q Inactive. ®Truck <br /> �1I <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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date <br /> m / m / m <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 f CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§1B462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: §, /1 <br /> Comments �fq��,•vL yilc/i 91h Anted <br /> �r.,Coi l~^7 (e ^�6retw4t. <br /> or u,`ee ofG(�_fr _,/�s Sa Qs o 14 [z l "S <br /> �5—t �- <br /> ✓•l,� Chen ve ✓lrf9eiz ZB��s nor.eP�, <br /> Inspection Form Included:Q � �M_996 <br /> WN (� <br /> Comments Included:Q- ({ 11/0 (a <br /> Business Rep's Signature Phone Number <br /> �/ inspectopfi Signature Phone Number <br /> X lJ I IE I)X IA IAA k IPLE 1 IZ :.23I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� . <br />