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08206040148 <br /> =_= Waste Tire Survey &Inspection Report Inspection Report Number ■ <br /> ere- <br /> °" statState 181 Calif(Now Survey Form - Page 1 1 3 - 1 0 7 9 2 6 7 <br /> CIWMB 787sNew nageW041Y g <br /> Cellfomla Integrated Waste Management Board `�J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q '') / Inspection Type (Fill one) <br /> Site Suffix: I ' 3 q T"I 0 Routine Q Re-inspection Q Referral Q Observation { <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: aj��J `I dl4�.µ� tJ/V 'T� Q CHP Q CIWMB Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name (/ <br /> �w �[� / Inspected By Inspector <br /> 1 vl�l/L T �1 Q/JS _d/��Ll� 'L <br /> Physical Address a g _ ?Address J � D / I ?A"( ttT-A44a" <br /> 2yyo Latit�r'S� /`F✓e I <br /> Street Inspection Date <br /> r(y State Zip Code Time In Time Out <br /> Business Rep Title O AMM O AM <br /> ��•- m' OPM 0P <br /> -AL 144 ~ - J Operational Status Tire Type Business Role Storage,Type. <br /> (Fill one only) <br /> Tire Count(Whole/PTE) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t. I ; <br /> I 0 Active Q Passenger .Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I L-— I I Q Hauler Q Indoor <br /> —__ D Q Inactive I*Truck <br /> Longitude - 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 p 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 E' _R_ EMENT S1TATlU_$-_ <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXTJ <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 1 CIWMB 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 1 Q Other: § <br /> Comments .O>k�Wb ,S,�QEYf—s3a /rt/a CXat�� /����aJ/% _ �✓�.p- <br /> _!?krc,.QC�.—/�'I_�fj�a-ids—✓_,���Y-._.uo ✓r\oi.C.,Y�S;=,S_�(�Gkr_Ca.<<.,s <br /> Inspection Form Included:Q 204 <br /> Comments Included:Q ( -'^- �8 Q ;Vtr <br /> Business Rep's Signatu Phone Number-- Inspector's Signature Pho��1B Number <br /> 62081 <br /> INSTRUCTIONS ON BACKorre Incorrect: X A h� P!L E: 1 ,2 3 ■ <br /> . White C y CIW Yellow Copy:Operator Pink Copy LEA <br />