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,... "Ii 09259050���5 <br /> Waste•Tire Survey & Inspection Report inspection-Report Number. <br /> State of 81(NrnW Survey Form - Pa a 1' I 1 - 1127500 <br /> CIWMB 181(New nage Y <br /> Califomla 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: , 1 j� 13 V J © l • Routine Q Re-inspection Q Referral Q Observation <br /> Local �� n 1 1 n (^, If Referral,choose referral type(Fill one) <br /> Identifier: <. 1 1 w� • t W�J1�'n _ <br /> Q CHP Q CIWMB Q.Complaint Q Educational Visit Q Other• <br /> Business or Facility.Name Inspected By Inspector <br /> Physical.Adtfress L�, <br /> Street — CP <br /> �s3l Xu <br /> e- InspectionDate <br /> uu CI}� <br /> __ 1 I <br /> City - State ZIP Code Time In Time Out <br /> Business Rep Title r0 AM <br /> �� •L O 41 PM- 1_It I ' I� PM <br /> - � _ - � <br /> .Operational StatusTire 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 /> I]Active ®Passenger ®Generator (9 Outdoor <br /> Q Closed Altered <br /> GPS Latitude I' t Q Hauler Q.Indoor <br /> Ji__ __ Q Inactive ®Truck <br /> Longitude : I Q Planned 4 OTR End-Use o Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 7 Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 1b Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility :ENF,ORCEMENTSTATUS; *�� ' a <br /> .., A HAU ING�AND MAMIFtES REQUIREMENTS:• Q No"ti Of VIolaatti nl*4 Extensi " <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires .•' oti Q on <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. omp lane Dead ne <br /> Q Q PRC§42956-Registration/Decal in Vehicles " <br /> t <br /> Q Q 14 CCR§18459 ' Responsible Entities Complying with Manifesting Requirements Date }! <br /> Q Q 14 CCR§18459.1 =Tire Program ID Number from CIWMB a <br /> four fJOU��r� ,� r• <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 . QReferrel; CIWB 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 <br /> 4 in Compllance *No Violations <br /> Q Q Other: § <br /> Comments 1 <br /> ia Ac ' <br /> C�INcsl'n- <br /> Inspection Form Included: - <br /> L �• � R <br /> Comments Included: ® — - - — — 1. =0���� � __ -__ <br /> Business-Re Signatur Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK C,°rre Incorrect:: X A �►h .P 2 g 62081 <br /> White Co CI B Yellow Copy.Operator Pink Copy:LEA <br />