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0925904.0593 <br /> =r , Waste Tire .Survey & Inspection. Report Inspection Report Number <br /> Stets B 181l(New Survey Form Page 1 I 1. - 11412 2 7 - <br /> CIWMB 181 stew 04101)' Y 9 I . <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type .(Fill one) <br /> Site Suffix: [CE <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `�Y� If Referral,choose referral,type(Fill one) <br /> Identifier: X./L Yv C.�l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L <br /> Inspected By Inspector <br /> 4, —H.G_Z.c�. C� IPhysical Adda19T <br /> _ <br /> - <br /> Streit <br /> le— ( / Inspection Date <br /> Cry/ r ! CcsJ Time In Time Out <br /> G l State ZIP Cods <br /> Business Rep � Title �kc� <br /> � � Q AM : � Q AM <br /> ® PM I 1 O a PM <br /> L. olper_-�Gabn�L_ ,LP�r_�s �'I,C?�_ - <br /> _ -- Operational Status -Tire Type. Business Role Storage Type <br /> (Whole/PTE). <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count <br /> Active ® Passenger ®Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude <br /> I - i• �`�� j 0 0 Hauler ®Indoor <br /> (� + 0 Inactive 0 Truck <br /> Longitude – F i ��; I I i 0 Planned 0 OTR 0 End-Use 0 Container <br /> I I I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet -0 Government 0 Retreader 0 Dismantler:. 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ®Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station _ 0 Hauler - 0 Agriculture 0 Shredder 0 Other I I <br /> PartB-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ' ,,�1/��A-x;HAULING�AND�MANIFEST�REQUIREMEN�TS •� �:�*_�'"' � b• ��. �wNo�tice�Of�"Ulfiota��, '� � '-�'�t � _ <br /> 0 Extension• <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ' t � <br /> Compliance Deadline z <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsDate F <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> ' >�uaed�for NOV or <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Lags for 3 years ` <br /> a <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referridl//CIWMB Enfo�t:ement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesAIR <br /> F <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O InCompflance .- No Violations ut <br /> O 10 Other: § _ <br /> Comments c)v-h n p ms an <br /> - e (to60r ccs e7ohfc� = <br /> Inspection Form Included:0 <br /> Comments Included:0 — — "`� m—t _ r t-l)–)`� -_ <br /> Bu ess Rep's Signature Phone Number 1 o s ignature Phone Number 62081 <br /> —- <br /> INSTRUCTIONS ON BACK AC' rre t: Incorrect: 4' Ir X R M .P L 2 3 <br /> White py YellDw Copy.Operator Pink Copy.LEA ■ <br />