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08129040862 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> C,Ze CelHornia Survey Form -.Page 1 14 - 1 0 7 2 8 1 .8 <br /> OHM181(New 06101) <br /> CalNomla Inffigrated Waete Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- rt O W Inspection Type (FIII one) <br /> Site Suffix: L 40 Routine Q Re4rispection Q Referral Q Observation <br /> Local �, If Referral,choose referral type(Fill one) <br /> Identifier: SA� 0�qQ„ ihVJ�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �`� =V�j' Inspected By Inspector <br /> Physca dr a <br /> Street <br /> dInspection Date —#f <br /> _ State <br /> Time In Time Out. <br /> Business Rep TitleEE-m O PAM 0 AM <br /> M EEI m O PM <br /> ©�N J 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 /> r i 1 Active 0 Passenger Q Generator 0 Outdoor <br /> GPS .Latitude Li <br /> - I - Q Closed Altered QQ` Hauler Indoor <br /> Q Inactive 0 Truck <br /> Longitude - ( I I I 1 I Q Planned 0 OTR 0 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 0 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> ULING AND MANIFEST REQUIREMENTS <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-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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/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 Q Referred I 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 Compliant No Violations <br /> Q 1 Q 1 Other. §, <br /> Comments �7 <br /> �o_✓L.3�8.e,/1�4sT� (ams/ H�e.ve be� d��e_.�/ �Jre:_pe.o.�e.�s—dam vI/ <br /> _,�cr,dcr�J iNtapQ6/�m� eld�,,,� cJa fu No ✓o/_ar�o�[s_oe �avcc�Is �Jor <br /> Inspection Form Included:Q �ZdR <br /> Comments Included:Q — <br /> 8usiness Rep's Signatu ne Rumber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rre Incorrect: X A M1 P L 1 .i2 3 <br /> ■ White Copy CIW M Yellow Copy Operator Pink Copy.LEA ® ■ <br />