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08038040302 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California - <br /> CIWT-1Mewoae<,. Survey Form - Page 1 1 2 - 1 0 7 9 4 2 3 <br /> Californla Integrated Waste Management Board <br /> Part A-Surve __ BLUE OR BLACK_ INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- 1 i f 151 �J I - EU_ <br /> Inspection Type (Fill one) <br /> Site Suffix:. l + / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /� _��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected Byy <br /> Inspector <br /> ISE <br /> - <br /> Physical Address T M01 / mmA ;eN <br /> .3 SS`f LtJ I <br /> Street <br /> l'1' A- Inspection Date <br /> ` 9SZ <br /> ii <br /> State Z!P Code Time In Time Out ' <br /> Business Rep Title O AM O AM <br /> MOPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> I I (Fill one only). (Fill all that appy) (Fill all.that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE).: <br /> Active ®Passenger ®Generator Q Outdoor <br /> DQ Closed Q Altered <br /> GPS Latitude Ll <br /> _ I ®Hauler Q Indoor <br /> 0 0-Inactive ®Truck <br /> Longitude - • ` Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy)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 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility PENFORCEMENT STATUS <br /> V A 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 /> 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 tar 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 Referred/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 Eomplfance - No Violations <br /> Q Q Other: § <br /> Comments hrc N AIN t* U LJ a- f <br /> y- C LSl -flea a `fL:Sorw 4a N4 <br /> Inspection Form Included:Q <br /> Comments Included:Q: 7785- <br /> Busi ess Rep Phone-Number 'inspector's Signature Phone Number <br /> e <br /> INSTRUCTIONS ON BACK �orrect:� Incorrect: FEW A M P 62081 E' 1 .2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />