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080ta040i79 <br /> Waste Tire Survey & Inspection Report, .Inspection Report Number <br /> State r[WMI 1SI(NCalifomla Survey Form Page 1 1 1 . 1 0 7 3 3 7 5 <br /> CnNNB 181(Naw 0001) <br /> caliromia 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: Ilq 3 ,:� jo U IQ R�Z_ ®Routine Q Re-inspection Q Referral Q Observation. <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /L. �riii L. Q CHP . Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> r [a:j]L—TI fl 5e-n 1rit c. ,,a 1;1 13 9 _ erg ,e ase <br /> Physical Address <br /> i ?, Soo Tcarh�i�e 7� • I <br /> Street <br /> St ck 11vi_ /5, (Lgj , I a l r l b <br /> Inspection Date <br /> City Q State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m' O PM O 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 /> ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude 7_�E <br /> D Q Closed Q Altered �J/A <br /> GPS Q Hauler Cl Indoor <br /> O Q Inactive ®Truck <br /> Longitude – F.-TI-1-1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENF.QRCEMENT STATUS <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. Compliance Deadline <br /> Q Q PRC§42956 Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0, 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 EX7) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 ompliance - No Violations <br /> Q Q Other: § / J,, n <br /> Comments R BLI'�C!� I Specfzc� 7(/1.l$ (/���.'e t 1/ 1� )'l.Qf COQ v <br /> `�t,i_.s�C_i. � — t�e�s I/Vt�l saYi I�/�j �i✓'e 1� �-�e � ✓;e� � oLc'spo.Rz.l <br /> 0`l !Ybe► e 5 _ _(Limed, Noy /a fe'uri s ad ed . <br /> Inspection Form Included: rtQ <br /> Comments In.lun. TL - 333 — L4b—/ <br /> 4�gBusiness Rep's Signature Phone Number Ins ct 's Sign re Phone Number. <br /> INSTRUCTIONS ON BACKa <br /> Correct: Incorrect: MP �L 62081 <br /> � EX1 :23 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA ■ <br />