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08157040105 <br /> k Waste.Tire Survey & Inspection Report Inspection Report Number <br /> rr etate of MB18ti(No. Survey Form - Page 1 1 5 - 1 0 7 9 2 0 3 <br /> CNYMB 181(New 04104) ' <br /> Califamia Integrated Waate Management Board <br /> Part A- <br /> Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- O © Inspection Type (Fill one) <br /> Suffix:Sux: - 0 Routine Q.Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �w.1 _, yt- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I ?asrraC <br /> Physical Address) <br /> 1 2314 % l, �oscm,;te .4✓e <br /> Street Inspection Date D / D / Fo <br /> 8 <br /> I -.c..� G4 4533�� <br /> C/y ' ' L0. tate ZIPode Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> _W f I. I?rFsl-dam ' -.� Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 9 Outdoor . <br /> J <br /> _—0 <br /> Q Closed Q Altered <br /> GPS Latitude I I I i Q Hauler Q Indoor <br /> �- -- _ _..-1--_ -- - io Q Inactive 19 Truck <br /> I <br /> Longitude - ; Q Planned Q OTR Q 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 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other � N � � �� I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATU <br /> 101A HAULING AND MANIFEST REQUIREMENTS Q Notice tJf Violation Q Extensio <br /> Q O I 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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/or 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 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 Complla ce - No Violations <br /> Q Q Other: §, <br /> Comments / J <br /> KIlIL[.rJ_•i_✓e. _Q_6S_�t/u-��� <br /> h U_bz._iN�NoT_�d- j�JS ,��.t-•-%1�!!�S-GS—�icr_oc�y�QS <br /> (l:_o_��io�✓S DR_/—�a.�Le���t/S <br /> Inspection Form Included:Q - <br /> Comments Included:Q <br /> Business R s i nature 1Phone Number Inspector s Signature . Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �orrec . Incorrect: I! X A hh P .LE 1 ,2 3 <br /> ■ White py:Cl B Yellow Copy:Operator Pink Copy:LEA <br />