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08066040051 <br /> « , Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ste (No. Survey Form = Page 1 16 - 1 01 0 8 4 5 <br /> CIWMB 181(New OI/a4) Y <br /> Canfomla Integrated WasteManepement Baerd <br /> Part A-Survey- BLUE OR BLACK INK PEN <br /> Business Profile. Inspection-Detalls <br /> TPID- / O / Inspection Type (Fill one) <br /> Site Suffix: 9 6 6 - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local C �f If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> no/� Inspected By Inspect <br /> I C I <br /> Physical Addr 9 3 9 f / <br /> I 302 6/ 7CG-,"4 c// <br /> Street /� <br /> C <br /> L [/ „ I9S-2/0 I Inspection Date <br /> City�''v �1O,r ( tate ZIP Code Time In Time Out <br /> Business Rep Title :MOAM O AM <br /> mem <br /> O PM O PM <br /> 'E r�' Operational Status Tire Type Business Role Storage Type <br /> ( <br /> Tire Count Whole/PTE a (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Is Active Passenger ®Generator e Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®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 ENFORC-EMENT STATUS <br /> V A AUL NG ANDMAN EST REQ IREM S <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 /> Q Q PRC§42956-RegistrationIDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E9Cl7 <br /> Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q ReferredF/[CIWMB1XffEFTforc ment <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: § <br /> Comments 2s*� 54'lc <br /> E-D i �e /titre- lf4 <br /> Inspection Forth Included:Q 3 <br /> Comments Included:Q—— <br /> Busi ss Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Insorreet; E X a NI P!L Ef 111213 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA - ® ■ <br />