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Waste-Tire Survey & Inspection -Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New04104) Survey Form - Page. 1. F Il - 11437 7 9 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: C��$�0�� - 1 Routine Re-inspection Referral <br /> Q P Q Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: Sayyul n_�l�lA� J( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l J1 Inspected By Inspector <br /> I_�7►a►t1t�0� F ltc,��j�e �101'�1�_ I � q - <br /> Physical Address I 1L�,� _—E. <br /> , „ —J <br /> 3� SO N_. UJ�1s�� wy I �-' WtA�J <br /> Street Inspection Date <br /> C <br /> City State" ZIP Code� Time In Time Out <br /> r 1 I C0 AM <br /> Business Rep Title I ' I� . , !,f I PM ;V`; ' ` J %PM <br /> Operational Status Tire Type. Business Role Storage Type- <br /> (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) q'3 <br /> l '• <br /> 40 Active Passenger ® Generator 0 Outdoor <br /> l0 Q Closed Q Altered <br /> GPS Latitude i 0 Hauler Q Indoor <br /> : 0 Q Inactive *-Truck <br /> Longitude - i I I ,I I I I i Q Planned Q OTR 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 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q CollectionQ Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other l I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQRCEMEIVT STATUS <br /> A `Ht,AUL'IIVG ANDjl41ANIFEST�REQUIREMENT;S" ,. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Eictension <br /> Q Q PRC§42953-Contracts with Registered Waste.Tire Haulers. "CompUance`Deadline ' t.;` <br /> Q Q PRC§42956-Registration/Decal in Vehicle. <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date /gym / 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 EXn <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 "H <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No;Violations �:4 <br /> Q Other: <br /> I :. <br /> Comments (QJt.OUIS�_f1S�Q,f �OrzV.S�1[,(' 01_1 ���-IDA-0-9 <br /> done-Ao ko- 'r\ )Cvo)0k_rL <br /> N9�sola ices o_s_�.cer��-off coc ap-A <br /> Inspection Form Included: Q <br /> Comments Included: — - - L0� �¢J-�o��- i ` (��_J/=1lSC-0�3�/•0 <br /> BiS iness Rep's .Signature: phone Number. Inspe is Signature,.:::. ` -�Phone;Number <br /> INSTRUCTIONS ON BACK. C- �� e 1401 Incorrect: "� E�X A �+ P Z Z 3 62081 <br /> Wh'a Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> ) <br />