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08206040083 <br /> €, Waste Tire Survey & Inspection ReportInspection Report Number <br /> Stateo181(omla. Survey Form -. Page 1 1 9 - 1 0 7 9 2 8 0 <br /> CIWMB 1gt(New OM04) <br /> calNomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPe - I n r7 / / Inspection Type (Fill one) <br /> Site Suffix: L L Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier; :5,J OAl 4 OA" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name) () ) Inspected By Inspector <br /> �-TAro W�ec�tJ2S I _ <br /> Physical Address <br /> f �1_� 9f <br /> Street <br /> Inspection Date .7 <br /> /► �/► � ry, �d7 SZ/_15"I <br /> city �— — State ZIP Cade Time In Time Out <br /> Business Rep Title <br /> Q AM <br /> 0 AM <br /> ST�Vc�. O PM Q PM <br /> Operational Status Tire.Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i OI n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ° I ®Active •Passenger 0 Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude W. — Q Hauler Q Indoor <br /> r O Q Inactive +�Truck <br /> Longitude I FF 7 III Q Planned 0 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 .10 Dismantler Q Tire Derived Fuel <br /> QUsed Tire Dealer QAuto 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 FacilityENFORCEMENT STATUS <br /> V A ,HAULING A N 01 MANIFEST REQUIREMENTS <br /> Q Q 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 Entities <br /> tVehicle / [T] / m <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 for NOV or FXT) <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 QReferred/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 Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> J3_Crrh._4 Al s# <br /> /atA 's s� Carrow rs3 /tJo T�c� <br /> Inspection Form Included:Q Z89 <br /> Comments Included: Ikiness <br /> �RSlgna�t�ure <br /> hone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co ect: I orre e : !<JXJ AIM P L-1 El 111'213 62081 <br /> ■ - <br /> Whil.7077 Yellow Copy.Operator Pink Copy:LEA ® ■ <br />