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08151040121 <br /> Waste Tire Survey & Inspection Report Inspection Report.Number . <br /> State of California Survey Form Page 1. - ( I 9 - 1 0 7 9 2 2 3 <br /> CIWMB 781(Naw nage <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fitt one) <br /> Site Suffix: D L Q Routine Q Re-inspection Q Referral a Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name I' Inspected By Inspector <br /> I �trwr /�,bNooy�—J <br /> Physical Address (_ <br /> Street t O 5 s D S <br /> S�G/UJ�'Yt Q`G�s Inspection Date <br /> City �� State JZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> F 1 10 PM OPM <br /> J 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 /> *Active Q.Passenger ®Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> Il J _ <br /> _j <br /> Q Inactive i Truck <br /> Longitude – I I I ( – Q Planned Q 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 O Others <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler-and End-Use Facility KENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST R-(QUIREMENTS <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 (Requi ed for NOV Or EXT) <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 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 Compince No Violations <br /> Q Q Other: § <br /> Comments o �f/ 01n1 <br /> to, - ) -Aa,,,,./ A/C) 0 7d+a3—�I.CLc u n 3 �t/oT y/� <br /> Inspection Form Included:Q �^ <br /> 4e8 9��.5 <br /> Comments Included:Q– -- <br /> Business R ignature Phone Number Inspector's S gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corrects Incorrect: E: X A M P 'L i' l 2 3 <br /> . While opy.CIW Yellow Copy:Operator Pink Copy.LFA, <br />