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OSIOSOSO067 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State orCaldornia <br /> °p CrNMB181(Now 04104) Survey Form - Page 1 I1 - 1088421 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - m Inspection Type (Fill one) <br /> Site <br /> Site Suffix: ` � � (j O $ O � 1D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �r Y) /L(� CQ7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "l� -" l! Inspected By Inspector <br /> Physical Address <br /> L_6_0-Z3 hA• Ma.r K s . <br /> Street <br /> 1Inspection Date' O z / a6 <br /> ������ Time In rimeOutL <br /> rty State ZIP Code <br /> Business Rep Title O AMI O AM <br /> Z <br /> Ez-7—o—idepm : L� ®PM <br /> ayl i� A-n eA__ (`'lana, e r <br /> -- -= ==-- -= Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) [� (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Active •Passenger ®Generator !Outdoor <br /> GPS Latitude O Q Closed Q Altered 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 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires. Q Notice Of Violation Q Extension <br /> Q Q P,RC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 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 I 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 1 Q 1 Other: § <br /> Comments KUu��YI�_ STPtf 8 J)A, -e C' ett�) <br /> l ►nen fsi 1' ti^e i <br /> -c YINI1r mare, .s e l r <br /> Inspection Form Included:Q 2j <br /> Comments Included: awl64-as -a ? _�" '=sw �- <br /> mess Rep`._13jgnat4W V Phone Number Inspe oes Si nature Phone Number <br /> INSTRUCTIONS ON BACK rrect: correct: (� X R P (, E 62081 <br /> 1 2 3 <br /> ■ .. White Co .CIW B Yellow Copy:Operator Pink Copy.LFA ® ■ <br />