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0916805001 <br /> cna: <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state B California(No la Survey Form Page 1 1 - 1088-048 <br /> CIWMa 181(New nage). y <br /> Callfornla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile f Inspection Details <br /> TPID- r ` T—I Q i F�T- - I I—� Inspection Type (Fill one) <br /> Site Suffix: i ;5 Ii ` ` 0 Routine 0 Re-inspection 40 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB t♦Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I_ TS 0 <br /> Physical Address <br /> �LJa1�et% <br /> Street j I 14-1F — <br /> Inspection Date �s c�+crn I_�ii°l <br /> c �'0 _ — _�-�— -� Time In _ Time Out <br /> Citi ----- State i';t'C::ia <br /> Business Rep Title [_;Q , j AM ��ff i : 8 AM <br /> O b j-O Q PM l l7 Q PM <br /> i—. ., j <br /> Operational Status Tire Type Business Role Storage Type <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whol PTE) <br /> t *'Active 0 Passenger Generator ®Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive I*Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS ® Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Fo4li <br /> a <br /> i 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 1 Other: n <br /> Comments ?)oYk� an—` h-s �Cb `�ee aYnm_.�r <br /> Inspection Form Included: ® ~ <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Ins a or's ig ature Phone Number <br /> INSTRUCTIONS ON BACK 15!7!ct: In orrect: X (a; VJ E X I Al IM I P t L E I 1112 3 62081 <br /> Whi Copy.CIWMB ow Copy.Operator Pink Copy.LEA <br />