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10160040406 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number . <br /> NE <br /> State of California <br /> CIWMB 181(Naw 04104) Survey_Form - Page 1 Il - 11274 81 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -1 Inspection Type (Fill one) <br /> Site Suffix: I iI 41 Routine _ Q Re-inspection Q Referral Q Observation <br /> Local C,. If Referral,choose referral type(Fill one) <br /> Identifier:, ..�ln �il�l� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> I_ oA Tcans1pdr6io>1 <br /> Physical Address <br /> - ► <br /> Moo Lnu,sc A <br /> Street <br /> pQ 3 Inspection Date , a / Ib a a <br /> rG1 ��J -L Time In Time Out <br /> city SI, to ZIP Code _ <br /> Business Rep u Title ' I QJ ; To 10 Am <br /> O PM L___)t I 'C33� 0 PM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) ' I,� ' (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) ' <br /> Active Q Passenger Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS l • 1_I� Q Hauler Q indoor . <br /> Q Inactive ®Truck <br /> O <br /> Longitude - I.,Fit <br /> ; Q Planned Q OTR Q.End-Use ®Container <br /> I <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 FacilityENF,ORCEMENTTSTA�U�S <br /> Vr A HAULING AND,MANIF.ES;T REQUIREMENTS.. . . a <br /> .. >•.�-,..°tea- ' ..t.'..`�-""•.�`.. MIS—T45 Q Notice Of olation Q Eztension�. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC 42953-Contracts with Registered Waste Tire Haulers. p <br /> § 9 Com Ifance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date fil <br /> Q Q 14 CCR 18459.1 -Tire Pro ram ID Number from CIWMB / m <br /> Q Q § 9 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required/or NOV or <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!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 Q Other: <br /> Comments \ 1n \or\ 0r —o�1 1� �Q <br /> (10 o_(\S_6S a fS. 5 <br /> F�►1; - mss m _ J1A <br /> Inspection Form Included:_QR"Vffd.^ <br /> .Comments Included: Q - — --�—— -—." <br /> - <br /> Busi esrf s Rep's i nature Phone Number Inspec is Signature7 hone Number . <br /> INSTRUCTIONS ON.BACK C rr�e Ilncorrect E�X AN�th 'P L Z 2 3 62oa1 <br /> ■ White Co :CI B Yellow Copy.Operator Pink Copy:LEA ® ■ , <br />