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09227040117 <br /> Waste Tire Survey & Inspection Report Inspection Report Number 0 <br /> ra, I1 — 1088386 <br /> Sute of California . Survey Form - Page 1 <br /> CIWMa 181(New nage 9 <br /> CallfomW Imeyrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1] ` Q O f�� Inspection Type (Fill one) <br /> site Suffix: �U� j <br /> I (0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI L If Referral,choose referral type(Fill one) <br /> Identifier: � .7O ' ,�'�q , N` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -__� V <br /> ` aC Inspected By Inspector �c, <br /> Phhysicalq�ess eJ �j -1 =10 L� ,! <br /> Street � � <br /> 33 Inspection Date <br /> Cit;' C�� Srere 7IP Ccya Time In Time Out_ <br /> Business Rep Tltle I 1 1 'O AM m Q AM <br /> 11x7_�► ---oWf7 --'_ 1- O PM — ---- O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' ®Active ®Passenger 0 Generator .Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> • O Q Inactive Q Truck <br /> Longitude - - Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> _#New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agnculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A ,HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> j 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date nj <br /> / m / m <br /> Q Q 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§15459.2.1-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/CIWMB Enforcement <br /> O 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 n� •d,Yl i --- 7 .{a c ,, 2S �AQH" �1 I <br /> — r ✓`''o_m -t4-e- titiirYs`C sa <br /> rwt s ✓i eWecf o V,D L `amsn�fi .y <br /> Inspection Form Included:Q l'�O'�� <br /> Comments Included:Q — �� <br /> usiness Rep's Slgn ure Phone Number Inspectors rgnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(% fr X R A4 P 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />