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08157094461 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cIWM8 <br /> SmmB 181 California w Survey. Form - Page 1 �I 7 - 10 7 3.4 3 91 <br /> (Ne0404) <br /> califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Tp,p- Inspection Type.(Fill one) <br /> 1-3- <br /> O � �Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local . If Referral,choose referral.type(Fill one) <br /> Identifier: 4-Sf}/J " CA C Co✓N 7T� 0 CHP "0 CIWMB 0 Complaint 0 Educational Visit"0 Other <br /> Business or Facility Name Inspected By Inspector <br /> P ysical Address <br /> L� _ I D7 <br /> L 7 l NgeDf <br /> Street <br /> t�TI � /CCCCc GGL/� � Inspection Date <br /> � tate Zlp Code I Time In Time Out <br /> Business Rep Title MOPM 0 P!­ <br /> O AM O AM <br /> - — I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE), { n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> ((I II O 0 Closed 0 Altered <br /> GPS Latitude 1 _�f� 0 Hauler 0 Indoor <br /> r (��O 0 Inactive jo Truck <br /> Longitude — I71 I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply)' " 11 <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 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 m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> i <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 i§In Compliance - No Violations <br /> 0 0 j Other: § <br /> Comments ;V$r ­1bJ ft Zkt5 0 <br /> 2 d�1L AA = <br /> Inspection Form Included:0 44,8 CW43 <br /> ` 9 <br /> Comments Included: <br /> Busines a ature phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect: Incorrect:XON-0 ?C A M P L .I Z 3 62081 <br /> ■ White C y.CIWM Yellow Copy.Operator- Pink Copy:LEA ® ■ <br />