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M <br /> 08206040137 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number � <br /> Steteor 181(Now <br /> Survey Form - Page 1 14 - 1 Q 7 9 2 5 1 <br /> Cg * (New nog <br /> California Intagratad Waste Managemem Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / � Q / 2 — / •Routine .Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifler: 15.#.j UN Q CHP Q CIWMB 0 Complaint . Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical I-� <br /> Address <br /> Street <br /> Inspection Date <br /> PCA <br /> city State Zip Code I Time In Time Out <br /> Business Rep Title O AM OAM <br /> 1 O PM m'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger O Generator O Outdoor <br /> r <br /> GPS Latitude �0 Q Closed Q Altered <br /> - L��'I_----- - I 0 <br /> Hauler �Indoor <br /> O Q Inactive O Truck <br /> Longitude — I O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture 0 Shredder Other L? rLe <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility -1111ENrO-EMENT STATUS <br /> V A HAULING AND MANIFEST REMUIREMENTS <br /> Q Notice Of Violatio <br /> O O O Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O P.RC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q Date y / y y <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIW MB <br /> O Q. 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O ------ - --- <br /> 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 Reterred I EIWMB 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 O Other: §, <br /> Comments <br /> An 3"a <br /> i —/omits*�/-r —Us-eSQo�Ad�_i-res—i4S 7h�.i rec,_�3Te�Je�f '7�'fi�e. <br /> �t-wl_ei�._ j�.s f' �'[e��_ No Cey►ce�s Oe U f/.'o/�f37`e��/�d-i�-.� <br /> Inspection Form Included:O <br /> Comments Included:Q Q(' 3 <br /> JB s Rep' nature Phone Number Inspector's Signature Phone Number <br /> ■� 62081 <br /> INSTRUCTIONS ON BACK C rest: I correct: Q X A NI P L E1 1 2 3 <br /> ■ White Copy: IWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />