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08227040116 <br /> Waste Tire Survey & inspection.Report Inspection Report Number ■ <br /> SFWMBCaifernia Survey Form - Pagel <br /> 1 8 - 1 0 1 0 8 8 8 <br /> CIWMB 181(New 041 4) <br /> Calif omia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection.Details - <br /> TPID- / - q Inspection Type (Fill one) <br /> Site Suffix: (J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: A^( QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> '6? Inspected By Inspector <br /> �T SANE ��,�_,r I 3 q - / o / <br /> Physical Addr ss 44D <br /> 1 234 T24c, /V� <br /> Street <br /> t 04 453 I Inspection Date <br /> City / State ZIP Coe Time In _ Time Out V <br /> Business Rep0 AM 0 AM <br /> CrTitle/ <br /> i "rC..�r'r IIIF� I O PM m' OPM <br /> LJ A <br /> _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE){ 4 r I r (Fill one only) (Fill all that (Fill all that aPPIY) (Fill.all that aPPIY) <br /> I_1 0 Active 0 Passenger <br /> 0 Generator 9 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader• Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body .Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder Q Other I J <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C^ompiiance 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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - ---- --- -- - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Waste Tire Generators In Compliance - No Violations <br /> 1010 1 Other: § <br /> Comments <br /> ' q �.1°�a <br /> -.j <br /> Inspection Form Included:Q �/d^9 <br /> Comments Included:Q 4 <br /> n el(. <br /> _ Business Rep's Signatur Phone Number Inspectors ignaturerTe Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ec Incorrect: f: X M P L l 2 3 <br /> . White Copy:CIWM yellow Copy Operator Pink Copy:LEA ® ■ <br /> ILE <br /> C P� <br />