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073400SO01.2 <br /> A <br /> Waste Tire Survey & Inspection Report Inspection Report Number , <br /> stab of"If"'la Survey Form -: Page 1 1 4 - 10 7 3 3 3 7 <br /> CIWMB 161(New 04104) <br /> • Caliromia Integrate.Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - / Inspection Type (Fill one) <br /> Site Suffix: f O J/ ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: �(, M I oCt /� Cep Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName Inspected By Inspector <br /> P6M �e C� eQ,ir 1 .emu lCra�� <br /> Physical Address [3X] - l 1 0 <br /> (J <br /> I I f I L4 " <br /> R <br /> Street CA- <br /> �O I <br /> Inspection Date [C6] / MO8 V 71 <br /> City State Zip Code Time In Time Out <br /> Business Rep Title ��� 0 AM 0 AM <br /> V77�U /"� J 0 PM O PM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE)i I I — (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ET 0; ®Active I0 Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude �• ®Hauler ®Indoor <br /> 1� O Q Inactive Q Truck <br /> Longitude - t_L 1 1 Q Planned- <br /> Q OTR ®End-Use Q Container <br /> 1 - <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 /> •1V1obi1Z ff0rv7e- 7yai�r <br /> Q Service Station ®Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -------------------------- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q I PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <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 E>,M <br /> Q Q 14 CCR§1 B459.3-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 1 Q .1 Other: §. <br /> Comments <br /> a RGill._ itis ►1.L.s_ e. Haat !1 + c(InS yi fi-om i Co— <br /> Ar <br /> ire 4-zspo,5 . and - CTL m.a.�st hrmt V'e_Viewe_ �}�_a� ein <br /> OF bVAi WI-IIVZ bt44X44 KUA MS -•Q M:anA_ sf ka Amon^ <br /> vy-D$ rs sife S asn _ r in rn�c#r Of- <br /> Inspection Form Included:® D ��jj�� <br /> Comments Included:Q �lV9_q �a <br /> Business Rep's ignature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:40 Incorrect: AA� 62081 <br /> �(� `dj EX �P ,LEr fl �Z3 <br /> ■ While Copy.CIWMB. Yellow Copy Operator Pink Copy:LEA ® ■ <br />