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08129040751 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Clate WMB81(NoCalifornia Survey Form - Page 1 19 - 1 Q 7 91 6 5 <br /> Cgrte 181(Now <br /> nage <br /> Callfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile — Inspection Details . <br /> TPID- / I Inspection Type (Fill one) <br /> Site Suffix: <br /> [:E <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local ��- ^ If Referral,choose referral type(Fill one) <br /> Identifier: Awl 1•!o4*Kjw1 COf1 i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I e',•t( <br /> Physical Address <br /> I_/D22 <br /> Street 0 Q / 1�1 <br /> 7�i <br /> D aVInspection Date 3 <br /> City /LAD State ZIP Code Time In Time Out <br /> Business ep Title :D_] AM Q AM <br /> 0 PM 0 PM <br /> i-- -l�►►�at - -- ----- ---- —FIs. �6� - I <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a,.,�'� <br /> f •Active Q Passenger &Generator *Outdoor <br /> O O Closed Q Altered <br /> O Indoor Hauler <br /> Latitude <br /> GPS I i•; i_ i O <br /> Q Inactive ®Truck <br /> Longitude — I { I,I I I i I Q Planned Q OTR O 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 /> i <br /> Q Service Station Q Hauler Q Agriculture. Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility IENFORCEMENT STATUS <br /> V ' A H ULINI AND MANIFEST REQUIREMENTS <br /> O O Q Notice .. V01111 to Q ensio <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Com lian Deadlin <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-11 MB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 010 1 Other: <br /> Comments <br /> Inspection Form Included:Q (zw <br /> Comments Included:044-9 44-9 7`�3 <br /> Business ep's Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> � EXAMPLE, 1 ,23 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy LEA <br />