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673120405363 <br /> Waste Tire Survey & Inspection Report Inspection Report.Number . <br /> _ _ _ <br /> Liz <br /> State or181(Nrnla Survey Form .Pagel i Z 1 3 2 9 0 <br /> GWM9 781(New 04104) y <br /> California Integrated Waste Management Board - J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Q _ /� Inspection Type (Fill one) <br /> Site Suffix: 1017 <br /> U ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local. If Referral,choose referral type(Fill one) <br /> Identifier: TO 06WI 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit. 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> .14I ,84 crs (8Vr-rtI`1IDYI Tire /•� <br /> Physical ddress 3 9 - V / LV __ <br /> �N�- <br /> Street <br /> Inspection Date <br /> City CState ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> G5 `e 0 PM EE 0 PM <br /> ICE ,t _ I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I _ ° ._� ® Closed 0 Altered-1 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS LatitudeFIT 0 Hauler 0 Indoor <br /> _ O 0 Inactive 0 Truck <br /> Longitude - FFTI. I rI TI 0 Planned 0 OTR 0 End-Use 0 Container <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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B- Inspection of Waste Tire Dealer,.Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> ON HAULING AND M904 I F.EgAl R.E0UIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of 1/iolation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1:Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest SysteML Requirements for Registered Waste Tire Haulers 0 Referred/C-IWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR.§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In C-ompliance - No Violations <br /> 0 1 0 Other: § <br /> Comments kot,.•�-0 n i nspecj `&" t PQA- tip 0F <br /> re 2 (51af_e B_ra mon +tre no /on_—err row'bi. or has S <br /> Inspection Form Included: 0SDD <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number I ctors§t6nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A P L E 1 `Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />