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08255090019 <br /> Waste Tire Survey & Inspection Report InspectionReport Number_ <br /> rr crwStatBt.allrNew SurveyForm* - Page 1 _ <br /> CIWMB 181(New 04/04) (� I 1 - 1088222 <br /> ca <br /> lnomia Integrated Waste Management Board �7 - --- - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- in <br /> spection Inspection Type (Fill one) <br /> Site Suffix: ' 3 I 9 7 3 _-� / f Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 4yJ JO/4l4.r.'-✓ 60tsrr,L I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> • <br /> Physical Address ----- - ✓ I � � ILfi4 /�---� <br /> C7 <br /> Inspection Date O I � Z ;(0 <br /> Time In Time Out - <br /> Business Rep Title O AM 0 AM <br /> O PM 0 PM <br /> t3R Q h QQ_ ✓!S d7 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Otherp.�+."4,f� SD—� <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 Notice Of Violation Q Extension <br /> Q Q <br /> 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 m / m / m <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 DCT) <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/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 /> Q Q Other: § . .__-.. -- - --- - --- - ----- - . <br /> Comments <br /> owAnt— P24Ar'c-- <br /> I i�Q ot.a_ +..^ ✓J i_d� 17 <br /> —�r_/_c k�-✓ �'Ia.�a.�,r��v_r'�'�.—No ✓�'o_/_�i�•t.s_e�.��,-s <br /> MOT's <br /> Inspection Form Included:Q C�9 <br /> Comments Included:Q <br /> Wuslnes:sR:A�nature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc : Incorrect:'�;"(J� EXAMPLE. 111,213 162081 <br /> . Whitepy CI B Yellow Copy.Operator Pink Copy.LEA ® ■ <br />