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09203050033 <br /> << Waste Tire Su0y & Inspection Repor Inspection ReportNumber <br /> � State of California <br /> CIWMB 181( eSurvey Form - Page 1 I 1 1,0869 5 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: L 1 J O 1 b Routine Q Re-inspection Q Referral Q Observation <br /> LIdentifier:ocal If Referral,choose referral type(Fill one) <br /> . J� �\n vt,l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> \_ P Y Inspector <br /> 1011Physical Address — I 11RIto <br /> Street <br /> 1 Inspection Date MO ) Kq� <br /> K*VState 13 ZIP Co'deJ Time In Time Out <br /> City —7 <br /> Business Rep Title O AM. 0 AM <br /> \ \ QPM D 'it PM <br /> --=- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> e .. . Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - I , I I iQ Planned 4& OTR Q End-Use Q Container <br /> I <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 Other P M A W_ �Ij <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS I <br /> V A HAULING AND MANIFEST REQUIREMENTS 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. C-ompliance 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 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 /> Q O 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 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 um—cv, �—�Q�.— C G n 11 __1 <br /> I,t^ <br /> M .7 MS1, I o(\ 44�lrii MUaL4S <br /> �'L3 Z <br /> Inspection Form Included: Q ?(?-3 "M440- <br /> Comments Included: • -- <br /> Bu ess 'gn -- Phone Number. Insp or's Signature.. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC C rrec : <br /> 'Incorrect: E. X A Ah P L E 1 Z 3 <br /> White Co Yellow Copy:Operator Pink Copy:LEA <br />