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U�066040043 <br /> ■ ..eir. <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> ;o <br /> tate <br /> Sof Califomla <br /> CIWMB 181(Na-04104) <br /> California Integrated Waste Management Board Survey Foran - Page 1 1 3 - 1 0 7 9 4 4 9 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 , l 7 Ll f I s 6 -3 I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `[b4yt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJ Inspected By Inspector <br /> Physical Address J 3 9 - 0 l A <br /> Street <br /> Inspection Date <br /> CAA <br /> 9s o� <br /> City Stale ZIPCode Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> F I 1 ®PM <br /> Operational Status Tire Type Business Role Storage Type . <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f ! <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> PS Latitude I _ i I Q Hauler Q Indoor <br /> G <br /> --- - — Q Inactive ®Truck <br /> Longitude J Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 'Q Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> I <br /> L <br /> Q service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> dcv�A <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility c�illnLt,u'ENIl__'_i AtiTUS _ _ <br /> V A ItHAULINGjAND■MANIFESiT R,EQ.U.IREMEN-- <br /> Q Notice Of Violation <br /> Q Q Q Extension <br /> 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 /> Q iQ 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 EXT) <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 <br /> (�c_Mhv►L—�n4Prk '�r mI-S—cllPthJ. C�S._s VJ;lS ny�_yvcuJi=rz <br /> —�O -ktY-u—k¢.rh rn, C-�_1t.—�C/l_-S—LGf_'l�i,f/5��� (�.f fazvu- Q�/_Ir/C�[��� • <br /> _�✓v��c vvr�.0 �..1 ct —G�c�c ��—cc2.�7-'/�r_c—cli-l�oo_tu2—,•r�E.�c/1!" <br /> —077 n �w— [ r—�SL� / c-,—�/olc�.t►N^s <br /> Inspection Form Included:Q <br /> Comments Included:Q —� j� Y��^O6�3 <br /> Business Rep's Signa re Phone Number spect.es Signature Phone Number <br /> -- • IEVAIM1011C I 1 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: l 2 3 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />