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08133040023 <br /> Waste Tire Survey& Inspection Report Inspection Report Number <br /> CrW.r solaol�atirorn� I t 4 . 1 0 4.0 8 6 8 <br /> .Calilomia lnteg nt dWaseMenaBlmant Board Survey Form - -Page 1: <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / . I _ Inspection Type (Fill one) <br /> Site Suffix: .2 I I 6 7 P1 <br /> I o Q 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: R� �Qvy1 O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I / 7?A0 /4� l7 4, I — <br /> Street <br /> f5�2_YO I Inspection Date <br /> Lp <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> ( O PM 'm O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) II II/� I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger 0 Generator 0 Outdoor <br /> O Closed O Altered <br /> GPS Latitude m I I I O Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - I I I J- _1 1 IV O Planned O OTR O End-Use •Container <br /> Business Type (Fill all that apply)__ 1111 1111 <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer p Auto Body 0 Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E FORCEMENT STATjUS <br /> Y A 'I HAULING.AND MANIFESiTi6REQUIREMENTrS <br /> 10 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Extension <br /> Io Q PRC§42953-Contracts with Registered Waste Tire Haulers. am Ilan De dline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 10 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate m <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or DCT} <br /> Q O 14 CCR§1 B459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 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 V'olations <br /> O O Other: <br /> „§ e , <br /> Comments V4,' • Q/Lty <br /> �v 4esef leeUd74o /esuodc V'i/ <br /> lry fc./csQ ovL h. ccYlQ. -1*Cou u I�i'ry a I a tuas<.' tr( Ak &4 y�y <br /> _e <br /> Inspection Form Included:Q / C''�¢/�., v/gam—OpfQ <br /> Comments Included:Q .�. � ��/ O4” 4V U <br /> Busin s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONSON BACK Correct: Incorrect; IEIXIAIMIPIIIE[ 1112131 62D8t <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br /> f <br />