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08129040$69 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> crNMBSurvey Form - Page 1 1 7 - 10 7 2 8 5 3 <br /> CONMB 181(New 04704) <br /> Califomla Inteeraled Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r/ ` 2 Inspection.Type (Fill one) <br /> Site Suffix: Ljj 7 I �/ r © / Routine Q Re-inspection Q Referral Q Observation <br /> Local C /1 If Referral,choose referral type(Fill one) <br /> Identifier: J�� Tt.> w.✓ 6o U"V TN- O CHP Q CIWMB Q Complaint, Q Educational Visit 0 Other <br /> BusinessInspected By Inspector <br /> or Facility Name /l <br /> � <br /> t->�r'r�s�nl �fP�6'�es � [�R - EKI �AuI FkeDEnl I <br /> Physical Address <br /> 1266-?- S. <br /> Street Q <br /> I Inspection Date <br /> L_ fs'332 , <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 94 <br /> / MQPM 11-1 Q PM <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 /> �/ <br /> 0 Active Q Passenger i Generator i Outdoor <br /> i L O Q Closed 0 Altered <br /> GPS <br /> Latitude I L <br /> �__L—_ L._I__ Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> O <br /> Longitude I I Q Planned Q OTR 0 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 0 Tire Derived Fuel <br /> I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder 0 Other I�+tE/rCr(o/ ry« _CoM�eT <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF,QR_C-EMENl STATUS <br /> V A HA LING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIW MB <br /> O 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 HaulersQ Referred 1 01 MB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 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 /> f_V.S /D5 9S �i—T_/a _Seevi�a�ov, e TDS -mac%SEs <br /> I} <br /> _T_Crtc.l� 7(Xts oN <br /> - IIAIVTr/eS n,= f O,� >�uJce. �� ✓,e/,o ho✓3_OR—r"aeLc �ILs �7 �. <br /> Inspection Form Included:Q <br /> Comments Included: - ���' <br /> urine s Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK7Coj <br /> Incorrect: XA <br /> M P''LE' 1 2 3WhiteYellow Copy:Operator Pink Copy:LEA ® ■ <br />