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i <br /> 08b66d4U048 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM r181(No. Survey Form - Page 1 1 2 - 10 7 9 4 5 6 <br /> ctwMB tat luew 041 4) <br /> California Integrated Waste Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> j TPID- Inspection- Inspection Type (Fill one) <br /> f Site Suffix: 3 1 ®Routine O Re-inspection O Referral O Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: TO�il�aiy� lusun�}- O CHP O CIWMB O Complaint O Educational Visit O.Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> Physical Addr s— m _ It Q 1 ' I f t+�P�'^ p6eXfitMMi <br /> �^ Inspection Date <br /> I �-.'o-L1E�t-arn <br /> City State ZIP Code Time In Time Out <br /> PM <br /> Business Rep Title Q� O AM Q AM <br /> _�r�T"�` yP�O �I �yLl.►1 '"Sf tFJ m•m®PM m m ® <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t i i t (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ®Active O Passenger O Generator ®Outdoor <br /> I 10 O Closed 40 Altered <br /> GPS Latitude � �I O Hauler O Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned ®OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet ®Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station ®Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facility ENFORC_EMEN_T_STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> OO PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dat. <br /> m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 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 /> 1�0�tvY�¢._L✓_If_PC.C�t�LY_N_n'r.� �-G CTL na.a��pdhCO- LG�1C?Y_1—�Z�Lw�.I� <br /> _�ke_�.�vt.•_,Lace�.Trr�e.c�...;�_q„c�rt_��Y_�ol�spo+!�.�-I .{c w_a.EF_gs_lvvoYf�- <br /> S.ra-�rt�{_�L►Mo#u�r-�Lda�.Vrr�i•_�r+o��e�_-t�t,4,�,,,—c1a,�wk�_rraud <br /> t _r�.l G�Lsp as�4rcc c�r�lsob �(—up,xr�rc .St ��-►tet opo�f SFt,xc <br /> aiV[o. _VS t ara.-. et...a( Q"Jeen ticd. NZ) VfOLe P7ta- <br /> Inspection Form Included:O <br /> Comments Included:O xCIn <br /> - X6 `a6Za <br /> Business Rep's Signature one Number `nrlure <br /> Phone Number <br /> INSTRUCTIONS ON BACK CorrectIncorrec'OX � lIENYIAIIMIP rLlEl11[2131 62061 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />