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I <br /> Q9253454�5i. <br /> wii Waste Tire Survey & Inspection Report. . Inspection Report Number <br /> .o ' California <br /> CIWMB1.87(NewOM01) Y Surve Form - Page 1 11 = 108 8 4 51 <br /> CIW <br /> California Integrated Waste Management Board <br /> Part A at Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 ' t Inspection Type (Fill oneP Q Referral Q <br /> Site Suffix: I 0 <br /> Routine Re-ins ection Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J (� {1_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bus ess or Facility Name <br /> Inspected By Inspector <br /> I__ fop u so _ups 13 <br /> Physics A dress � LPA>n <br /> IStr 1 'bo� n�. <br /> LI 9 5-atInspection Date © / IM3City-- \ State ZIP Coude I Time In TIme Out <br /> Business Rep Title u O AM 0 AM <br /> CO. � � il 1 ,5 11® PM �J0PM. <br /> Operational Status Tine Type Business Role Storage Type ' <br /> (Fill one only) (Fill all that-apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> --:0 Q Inactive Truck <br /> Longitude - 1 I Q Planned Q OTR Q 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 Q Agriculture Q Shredder Other j <br /> �-- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1ENRORBEIVIENT STATUS <br /> V A HAULING NB MANIFEST EQUIRE E S <br /> ® No <br /> Q Q ice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Com liance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> .0 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 DCT) <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! -IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> f Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violati ns <br /> Q 1 Q 1 Other: § ' <br /> Comments R11 <br /> Ow 40 - N P1 <br /> _C tz Q L ,�� 401 ck i Q <br /> Inspection Form :nc <br /> ncluded: Q +33 LIAL-Aw <br /> l/s, <br /> Comments luded: 0 -- — <br /> Bu ' s Rep's ture Phone Number Inspector's Signature ne Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co ect: ncorrect: X A ifi4 P L 1 2 3 <br /> White-Copy: IWMB Yellow Copy.Operator Pink Copy:LEA <br />