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08123040954 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> „ Stat.of California Survey Form - -Page 1 1 8 - 1 0 72 8 79 <br /> CIWMB 181(Naw oaoal <br /> Califomia Integrat.d Wast.Management Board - - <br /> Part A-Surma BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- fpm Inspection Type (Elle one) <br /> Site Suffix: L 2 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sR/J I'/J_�J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> eye <br /> Physical Address <br /> W . Lt LbI i 1_74A <br /> '.. Street <br /> Inspection Date <br /> INIA N T�(,.4 CA95 3 3� <br /> City State ZIP Code I Time In Time Out <br /> Business Rep Title O AM O AM <br /> D QPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) . <br /> 0 Active ®Passenger fO.Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I I I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> I O <br /> Longitude Q Planned Q OTR — Q End-Use 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 .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 ENFORCEMENT STATUS_ <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date m / m / 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 EXT) <br /> Q O -- --- -- .__ <br /> 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: § J <br /> CommentsU�SALa'T�t�Lf <br /> _pBuY-+�1_E__riV��Qr-cT�J�1 dlnJ 77fe� e�� Jl_ <br /> 1 V,4P_td scs �s- <br /> �� <br /> inspection Form Included:Q <br /> Comments Included:Q <br /> Business Re 's Signature Phone Number In pector's Signature Phone Number <br /> BAC <br /> t INSTRUCTIONS ON K orr ct: Incorrect: ]( 0 X R M P E. 1 2 3 62081 <br /> . ® ■ <br /> While opy C B Yelli Copy:Operator Pink Copy.LEA <br />