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08129041110 <br /> eoe_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr data or Calilornla <br /> CIWMB 1811N-04104) Survey Form - Page 1 . 1 4 - 10 7 9 15:2:1 <br /> calltomla Integrated Waste Management Board <br /> Part A-Su= _BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 13 1 �j 1617191 <br /> ( - ^ / Inspection Type(Fill one) <br /> Site Suffix: I (� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name -— <br /> Inspected By Inspector <br /> —f— — <br /> Physical Addreds W FiTo <br /> I _J <br /> Street �j <br /> ' L 22 O J Inspection Date <br /> City C' 1_f <br /> J State ZIP Code Time In 1 Time Out U <br /> Business Rep —UU�— i�,,,Titlee }��^ Q AM Q AM <br /> !fr_IG J�_ 'Vire m EEO PM m m O PM <br /> Operational Status: Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ®Active O Passenger I&Generator ®Outdoor <br /> I I O Q Closed Q Altered <br /> GPS Latitude L I I� Hauler Q Indoor <br /> _.__--_ 0 Inactive ®Truck <br /> Longitude - I I I I __f - 17PO O Planned O OTR O End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service station O Hauler O Agriculture 0 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 /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Win compliance - No Violations <br /> O O (Other: § <br /> Comments —�VWIdcC,IW'l dL <br /> ,��.�,��� Tcr.2 ✓'eyr►�V� �Gt1VQ�S�`�'P �''eS Cu� CLt � �� L_ <br /> -FC(t)n st-k- Ar --Cc _a -- i vLSi � if �Z-_ fr*L <br /> f <br /> Inspection Form Included:O <br /> Comments Included:O <br /> Business Rep's Signature Phone Number Inspectofs Signature Phone Number <br /> • �( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EI X A M P'L E 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />