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082270400SE6 <br /> ■ t�eu Waste Tire Survey & Inspection Report Inspectipn Report Number <br /> State of <br /> CIWMB 181(Neww OMOd)CahrerSurvey Form - Page 1. 1 - 10 10 8 8 1 <br /> ' <br /> ' Callfomia Integrated Waste Management Board • <br /> Part A.Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D e� - Inspection Type (Fill one) <br /> Site Suffix: I (� 2 9 D / Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,q „� �N _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or�Facility Name may'—V V Inspected By Inspector <br /> I l 'k4 e e_ <br /> Physical Address ✓ / t� L'/ � / D !� <br /> I <br /> 21>-57- <br /> Street <br /> Sra Com- l 5 <br /> 2 p Inspection Date 6 M_ V <br /> 0 8 <br /> !ty State ZIP Code Time In •Time Out <br /> Business Rep Title O AM O AM <br /> O��N% Tylesm• mOPM m'm 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I161 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' jo Active Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m Q Hauler ' Q Indoor <br /> D Q Inactive le Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> le New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 40 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 MENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of 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 Date mm <br /> / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or FXT) <br /> Q O --- --- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 year's <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!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 C-ompIlan <br /> ce - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> tJ&d Ak 1 _0/� <br /> i/1 <br /> -�..•a^/�,. <br /> I'y/Lt.k f V►�tct�.R_CY .. 'j O ofy I s7��:O+qs O r (r erg C a.h 5 O i*cS. <br /> Inspection Form Included: Q / ,�{2�9 <br /> Comments Included:Q—f.�akam.i_ -1..6� I <br /> Business Rep' nature Phone Number Inspector's ignature Phone Number <br /> ■ <br /> INSTRUCTIONS ON BACK E X A P .LE 1112131 <br /> 62081 <br /> Wh <br /> Yellow CopyOperator Pink Copy:LEA ® ■ <br />