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08038040306 <br /> eee- <br /> Waste Tire Survey &Inspection Report Inspection Report Number <br /> State C(WM 181(Califorale Survey Form - Page 1 1 4 - 1 Q 7 9 4 Q 9 <br /> Cgrte 1811sNew nage Y <br /> Callfomla Integrated Waste Management Board. <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I t I Q I I O r Inspection Type (Fill one) <br /> Site Suffix: 1 l 0 Routine O Re-inspection O Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 1. ( ry,a fir.► O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name 1 - <br /> �A Inspected By Inspector <br /> Physical Address 0 h I r r„`cerylG�e_aCsetyH <br /> IZn,I I <br /> Street <br /> �^.An Inspection Date <br /> � ,p C� $2 <br /> City C r SjbTe Zip Code Time In Time Out <br /> Burliness Rep Title 0 AM 0 AM <br /> m'm m PM m m ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L 0 Active O Passenger (lb Generator 0 Outdoor <br /> GPS Latitudef 0 O Closed O Altered O Hauler 0 Indoor <br /> �-__I__I'I _ I___-� __�_�J O Inactive (a Truck <br /> Longitude O Planned O OTR O End-Use O Container - <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®Auto Repair O Trucking Fleet O Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility&IM&M-1 r <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notrce of Violation O Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 FXT) <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 O Referred 1 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 C-ompliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> ��Lt-.}�, •�r�.k.�-.s VGI�.�c3.�r .,.. � �s�� l�xc_ ——Hr2- - <br /> i-Y '-�t-t'—G �►1Qf �t�w a�tt7 YZSt�1rt n✓ y ucJ Q C�fGln.�SCtS_. <br /> �f I <br /> V <br /> Inspection Form Included:0 <br /> Comments Included:0 xQ L�le�_Ob Z .3 <br /> Buten ,,/ e ' re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IIxIAII P[ I 111,2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />