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i <br /> 08123041072 <br /> cer. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> ;rr state of California <br /> CIWM8I8I(New04/e4) Survey Form - Page 1 �_I 6 --- 1 0 7 2 8 5 2 <br /> califomla Integrated Waste Management Board - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile inspection Details . <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I 0 Routine Q Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) . <br /> Identifier: 1 54"j (n Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Q /V/ Inspected By Inspector <br /> Physical Address [3R] - EH�] �, �04A_6&22 <br /> Street / <br /> Inspection Date <br /> (�S_to�.�,�1 _G.4 9522 I <br /> dy State Zlp Code Time In Time Out <br /> BusinAess Rep Title 0 AM 0 AM <br /> LLI' O PM LE'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 .1 <br /> f ; (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r - t 1 •Active Passenger 4D Generator O Outdoor <br /> Latitude % ( - I I I j0 O Closed Q Altered'tQ O <br /> Indoor <br /> GPS __1-_ I_•J_ _J_J <br /> M <br /> O <br /> Inactive �Truck O Hauler <br /> Longitude - I •` I 0 Planned ®OTR O End-Use Q Container <br /> Business Type'(Fill all that apply) <br /> New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler ----QTire Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer' Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Other 6Z,(e4-/d,4vf gccaY.; <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORC--Emus- STATUS <br /> V A HAULING ANO MANIFEST REGpUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ Referred/C-IWMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 101 Other: § <br /> Comments Pur. p _ O �O��OW�N9 u!'�c .✓ q� <br /> _L—�IJU_'v�T_L_f(!S_f.S �1.lGrLT 2£� /_45�R ✓�%SfZ./-',c c,��.J�4s-i�T_'i:,¢�—`i4w'le,e_ <br /> o LO-6.T•'crn��oQ <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signatur# Phone Number Inspector's Signature ---Phone-Number <br /> 62081 <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI 11 f2131 <br /> ■ WhiteCo CIW Yellow Copy:Operator Pink Copy.LEA ® ■ <br />