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09259040605 <br /> - Waste Tire Survey & Inspection Report - Inspection Report.Number <br /> State of California <br /> CFWMB 181(New 04104) Survey Form - Page 1 I1 - 1127648 <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: ��/ i���Y��� �� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I n r�U If Referral,choose referral type(Fill one) <br /> Identifier: l f \ n/n -` ' — Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other' <br /> Business or Facility Name V. Inspected By Inspector <br /> - - N_.__- -- -- - - - -- -I-I <br /> Physical Address - loll I I <br /> 9. <br /> Inspection Date 9I <br /> T. 0 <br /> L�—:I <br /> L - <br /> Ciiy '" -'- --�� Sta—L —ZIP Co�e Time In Time Out <br /> Business <br /> - -- <br /> —_ <br /> Business Rep Title I <br /> O i i :1 � Q AM [ I ^ 'S Q AM <br /> — PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 0 Active Passenger ® Generator Outdoor <br /> - I D Q Closed O Altered <br /> GPS Latitude I J I y -—; I—.{ O Hauler O indoor <br /> O Inactive O Truck <br /> Longitude Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader ® Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler 0 Agriculture . Q Shredder Q Other t _� <br /> -Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS" 'Y`" <br /> tlyo . <.. .. _ ,. ;f':-r <br /> HAULINGmAND MANIFESTREQUIREMENT;S7. -, N � �� ` <br /> once Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. -C-66 <br /> pliance DJAwdne <br /> OO PRC§42956-Registration/Decal in Vehicle t .r <br /> O O 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements bate m � m /rm <br /> OO 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requk%for NOV or DCT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§1a460.2-Manifest System Requirements for Registered Waste Tire Haulers- Q Weferred t CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Com Mance No'Violatlons <br /> ® p < <br /> O O �.., <br /> Other: <br /> Comments �s vl•Ll.l G nofa_,� -7Yk Jq/l ot,t o_. <br /> �uCili- KSes <br /> WkVJf,rl/�C� e—TZr.e & sa EbT y_� s �er�ns <br /> VL e1e� os`Iyrne�sf cU^e �¢ _ s /metre aQs o <br /> s .firCtl�s� Q 3 p,�rs��e— wo <br /> Inspection Form Included: 0 �`l0�(�i��C�%"rcJ `UGU -` 9&& <br /> Comments Included: — <br /> Bu 'Hess Rep's Si lure Phone Number Inspecto Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK 1X AIM P I L E 1 2 3 <br /> White Cop :CIW Yellow Copy Operator Pink Copy:LEA <br />