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08255040024 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state rr C1WM 181IN—CalifomiSurvey Form - Page 1 1 4 - 10 7 9 3 0 1 <br /> CMa t c 161(New nag <br /> California Integrated W.M.Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / n D J D Inspection Type (Fill one) <br /> Site Suffix: s� 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: q DiuL� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 66'�__�� Inspected By Inspector <br /> P-.9- '5 <br /> Physical Address � tJ � I S�ia,a-s-j,v��✓t1 � <br /> y187 til/ G,► <br /> Street <br /> 77Sss�lJ Inspection Date <br /> City State ZIP Code Time In Time Out <br /> x <br /> AM <br /> Buus� IOS�iiness Rep Title/- Q 0 AM / O PM <br /> C 'L'rc./' /'"�f' -- �{ 4�! -- O / O O PM ` D <br /> I <br /> 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 /> (a Active ®Passenger ®Generator (a Outdoor <br /> j !O Q Closed Q Altered <br /> GPS Latitude -1 I- - --, - - Q Hauler Q Indoor <br /> _- - -- _._ O Q Inactive Q Truck <br /> Longitude - 1 _ Q Planned Q OTR Q End-Use Q Container <br /> _�_ _ � <br /> Business Type (Fill all that apply) <br /> ®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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING ANB MANIFEST EGlUIREMENTS Q otice Uf Violation Q Extenslon <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 FX7J <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/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 Csompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments Zc¢ Jr �.3• G�Q/w//,"p�4Gs Q�Gt� /Zyo Gt/Y'S koA'l � <br /> �%�/ f Yi*✓� Lt�tr9» /e - �s».1'. /Q" <br /> Inspection Form Included: 1,22-2 af <br /> Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect: P E X A M L E; 111, 62081 2 3 <br /> . White Copy CIWMB Yellow Copy Operator Pink Copy LEA <br />