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03210040294 <br /> "eee_ Waste. Tire Sur*y & Inspection Report Inspection Report Number <br /> State of California <br /> i CIWMB 181(New 04104) Survey Form - Page 1 Il - 10880 6 0 <br /> Califomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- R z y Inspection Type (Fill one) <br /> Site Suffix: v I v ( I-o-Di ® Routine Q Re-inspection Q Referral <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ao ah—Com Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address ! O R <br /> Street <br /> Inspection Date 0 <br /> LLjy�ev� 36 I Time In Time Out <br /> City t� ZIP Cade <br /> Business Rep Title Q AM O AM <br /> 0?1i ' �� V ® PM ® PM <br /> ' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) : <br /> (Fill one only) (Fill all that.apply) (Fill all that apply) (Fill:all that apply) <br /> � � ' <br /> Active ® Passenger ® Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude ,' I i ; Q Hauler Q Indoor <br /> L �_ <br /> --- - -- — -- — — Q Inactive Q Truck <br /> Longitude - ;! ^'� I i io Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair. Q Trucking Fleet Q Government p Retreader Q Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler OA griculture Q Shredder Q Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RENEORMEMEN1 TATUS <br /> V <br /> =11H. AND MANIFEST REQUIREMENTS <br /> Q Notice Of violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 forNOV or EXn <br /> Q Q 14 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 C-IWMB 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-ompliance - No lfiolations <br /> Q 1 Q 1 Other: <br /> Comments Pliau6ne, �Y1�S.�7e t-1Ur l�A_✓1��7Y1� 113— U ►/- o��CKl��1 - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signqure Ohone Number -In pctor' Agnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: correct: 0 X M P ?L E. 111-21-31 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy.LEA <br />