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07312040455 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ rr'° <br /> State of Survey Form - Page 1 1 6 - 1 0 7 3 5 2 9 <br /> CIWMB 181 stew nage y <br /> California Integrated Waste Management Board J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- g ' a I - O / Inspection Type.(Fill one) <br /> Site Suffix: ''� I 0 Routine . Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) .. <br /> Identifier: SUti1 (�p� � Cyu y�ki� Q CHP Q CIWMB .Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> [itil(Physical Addrr essI / 0_[_1 ^ . <br /> Street 60 <br /> _ �7+ Inspection DateG�z <br /> city � State P d Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> : -1-10 PM [1-1- ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i ii I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r' I.1 I ®Active ®Passenger ®Generator Q Outdoor j <br /> I� l <br /> Latitude Q Closed Q Altered <br /> Q Hauler Q indoorGPS DO <br /> Inactive Q Truck <br /> Longitude - ,� 10 Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) 111 <br /> 10 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 t <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EN_FORC_E_MENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 Date m / m / m <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 orF_X7) <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 I CIWMB 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 Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> /sc�1t,Y.�ar-mrot <br /> �Ca <br /> o�-C, o f <br /> I <br /> Inspection Form Included:Q 7r,, <br /> Comments Included:Q- t�� �� �o$ �� <br /> Business ReV-s nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrec Incorrect: 4VE X AMPILIE1 1112131 <br /> ■ White py C M Yellow copy.Operator Pink Copy:LEA ® ■ <br /> l <br />