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08227040191 <br /> jWaste Tire Survey & Inspection ReportInspection Report Number <br /> State CWN1 181IN..CaliforniSurvey Form - Page-1 15 - 10 7 3 4 5 3 <br /> CIWMB 181 thew 04/o4) <br /> Califamla integrated Waste Management Boor d , <br /> Part A_. <br /> Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - O �j Z - / Inspection Type(Fill one) <br /> Site Suffix: 15 <br /> I I ! 13 T 0 Routine Q Re-inspection Q Referral Q Observation . <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: . S(}�! 'j—.A ✓t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> 61 Y <br /> Business or Facility Name Inspected By Inspector <br /> CH � `1 t ''AAn� --tt <br /> (Physical Address I D ' 11_''-►�' _M <br /> I 3gs W, 611-A,J7- Ull 2d <br /> Street C4 q <br /> 5 3�� Inspection Date <br /> I <br /> city State ZIP Code Time In Time Out' <br /> Business RepAA Title O AM Q AM <br /> IT-De-Tve. t—A"A L/7� — 9614 - m 1E0 PM m'FO PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> T I ; i (Fill one only) (Fill all that apply) (Fill all.that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) (/� <br /> Active Passenger .Generator. 0 Outdoor <br /> TFT <br /> Latitude rO O Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 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 .4j 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF_ORI EMEN1T STATUS <br /> V A ,HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 Ior NOV or EXT) <br /> O I 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/CIWMB 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 /> O Q Other: § <br /> Comments / <br /> _�_ -�.�j—cc.a��a�rno�,r—��� �A-�'1+�%► r�is}_-.o..j•Jc� 7_�i_'r+c <br /> l <br /> C•Nt:_�ks .r_r�_-- <br /> Inspection Form Included:Q ZOQ <br /> Comments Included: <br /> ess R Sig turePhone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS 0 ACK Correct: Incorrect: E X A M P J 1 12 3 <br /> E <br /> ■ Whi a Copy CI Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 1 U <br />