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V 8262 V`N4 0 sS°n! <br /> ees- <br /> Waste Tire Survey & Inspection Report Inspection.Report Number ■ <br /> ir State of CalHomia <br /> CIWMB 181(N..04104) Survey Form - Page 1 1 2 - 1 0 l 9 3 Q <br /> Califomia Integrated waste Management Board <br /> Part A-SUrVZ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �I Inspection Type (Fill one) <br /> Suffix:Site / . 3 3 S 7 9 7 0 / ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: C//Qq�'J;� 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name a <br /> spected By Inspector <br /> Physical Address <br /> I /SO/ - <br /> Street //4 <br /> Inspection Date <br /> OS�9� <br /> City State ZIP Code Time In Time Out <br /> Business Rep. Title ®AM 9 I ®AM <br /> -- — �I- low"W Ia Q PM ® / S O PM <br /> rs� <br /> - - Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ± IS <br /> *Active 0 Passenger 0 Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude I <br /> GPS Li"Ll-L�I _1 0 Hauler 0 Indoor <br /> I O <br /> 0 Inactive ®Truck <br /> Longitude - 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 Retreadeir 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> &A MjIN):%ULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 <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 FX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> A. <br /> Inspection Form Included: <br /> Comments Included: - -J1(,Q-l� - — <br /> Business Rep's Sig a e Phone Nurtitter Inspectors Signature Phone.Nurilb_er <br /> -62081 <br /> INSTRUCTIONS ON BACK Correct: i,Incorree"ta1XIhJ�1� !( A MI P;L l 2 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® . <br />