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08052040233 <br /> [BB- <br /> Waste Tire Survey & Inspection Report Inspection Report.Numbertate of . ■ <br /> S'9WCalifornla Survey Form Page 1 1 9 - 1 0 7 9 4 4 6 <br /> CBNMe 181(New 04104) <br /> CaliforniaalIntegratedted Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 01'/ 3 171 .3 O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier. Sall Cyd� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address3 (J- L 13��• I <br /> Sneer <br /> Inspection Date <br /> gS2aG <br /> City � r CAState ZIP Code' Time In Time Out <br /> [7� <br /> Business Rep Title ®AM 0 AM <br /> OPM 0P <br /> �►e.. vl-- —t- - h°r --- <br /> - IE <br /> Operational Status Tire.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) !6,10 <br /> ' <br /> 1 1®Active ®Passenger Q Generator Q Outdoor <br /> _--- — -- - -t - —�•- �---�_- 0 Q Closed Q Altered <br /> GPS Latitude �-J•L_- � J i ( Q Hauler Q Indoor <br /> —J-�J Q Inactive Q Truck <br /> 1 I I Q End-Use Q Container <br /> Longitude - I _ I I•i I I I IO Q Planned Q OTR <br /> Business Type (Fill all that apply) 1 <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government . Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V j A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Df Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 /> Q 014 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.Wasle Tire Generators ®In C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ku+�t�>}`"�—•�srx�.h�w._a+•• "arc da42t.� _� cls._rL�/j11T�r _ s . <br /> rCC�i 3 ey, tec <br /> ��'.t.ksccLcd�—/aeea4m+-_ _ dr.�se,L-r- f'NeLec�t�+%l�yns <br /> Inspection Form Included: �spe� <br /> Comments Included:Qat/._.------ — <br /> Business Rep's ate one Number Inctor's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK - e- IEIXIAIMIPI 1 2 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />