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08206040139 <br /> == Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> 1. <br /> CWMB1al"O' Surve Form Pa e 1 11 - 1 0 1 9 2 4 9 <br /> CIWMB 161e(New nage y <br /> Califomla Integrated <br /> Waete Management Board J <br /> PartA-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID I —® I— Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 1111 ' ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. I s � u� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By. Inspector <br /> Physical Address g - IS <br /> Street o <br /> Lit. /o�0 eA 95 Inspection Date 2 r D <br /> City r State 3ZIP Code Time In Time Out <br /> Business Rep Title O AM <br /> F�OAM <br /> O PM m'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> I 0 Active Q Passenger 0 Generator ®Outdoor <br /> r 7I0 QClosed Q Altered <br /> GPS Latitude I I J I I I I I Q Hauler Q indoor <br /> I IL—JI— r �0 Q Inactive •Truck <br /> Longitude - I -J_ I I I '�I I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all tha{{tt{tt apply) _1111___ III_ _ I <br /> S New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> •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 I I <br /> Pv HAUL NGiAND MANIFE-ST�EQUIR MENTiSart B-Inspection of Waste Tire Dealer, tor,Hauler and End-Use Facility Q Nonce Of v oiaSoA Q <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Extension <br /> I <br /> Q ,Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complia ce Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 <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/C WMB 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 I In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments ' <br /> iC �tL� S,lOje2./e--��+'0^1 <br /> btl_P�Q-- V 4✓ t.(w� i%t. - /ti/ d <br /> r�'r5 a..._1� �< LtG-...,Q..,✓� /yla.,.ti-.✓✓, � �r fJ�o.� � �tlo ilio/A�LJwJ <br /> dI Gay,CA,Ns AA 71-./ <br /> Inspection Form Included:01 <br /> 2 <br /> Comments Included: <br /> ���"" BBBUUUsiness R ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Lorre. : In¢orreet: I EV AIMI P I L I E1 I I J.2I 31 62081 <br /> ■,.. White C py CIW B Yellow Copy.Operator Pink Copy.LEA ® ■ . <br /> L <br />