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08128040748 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> statoe181(Nrnla Surve Form - Page 1 1 1 - 1 0 7 9 17 4 <br /> CIWMB 181(New na"ga Y <br /> CalMomla Integrated Waste Management Beard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - Inspection Type (Fill one) <br /> Site <br /> Site Suffix:TPID Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� n <br /> S/.� 1 �J 0.4Rit.�1/•r C..�+�'�Y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - o r w�e�fN i <br /> Physical Address�-�.s t <br /> t E-�ef(w►a.... �Za. <br /> Street O <br /> S6 <br /> � ^A 95 20-2i <br /> Inspection Date <br /> — <br /> City (•State ZIP Code Time In Time Out <br /> Business Rep ' II Title [=0 AM O AM <br /> :�Yte MM� -- �:4AL�"� � t - O PM O PM <br /> - Operational Status Tire Type. Business Role Storage Type <br /> l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t, <br /> r r 0 Active i Passenger •Generator 0 Outdoor <br /> io Q Closed Q Altered <br /> ' I <br /> C7 P.5 Latitude - �- J•i- -- -'--I Q Hauler Q Indoor <br /> L <br /> _ _ Q Inactive Q Truck <br /> I fQ End-Use Q Container <br /> Longitude - i (,I ! I I I Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q 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 40 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 ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data 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 or EXT) <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 /> 1010 1 Other: § <br /> Comments �ajK-1.17-'G-.�/_Jf�p_4�fT-dY-)-O.7'�!/ILS-�R.f-G-.-/yr3/��G_�—�i-•fid—.�w!Tk:Kad <br /> r. %s_1k,�.�fisc I/ar�uS dim',+ �..dr'1��, %Ji�,T �r�.�/irt Sept✓rC.c_�Tr+c <br /> AAV,;5 L,1_7 <br /> Inspection Form Included:Q <br /> Comments Included:QDJXA- — - - <br /> Business Rep's Signet a Phone Number Inspectors Signature one Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: (� X RMP L e 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />