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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Surve Form - Pa e 1 1 8 - 10 7 3 4 4 8 <br /> CIWMB 181(New Oa10�) Y <br /> California Integrated Waste Management Board <br /> 'art A-SUrvev BLUE OR BLACK INK PEN <br /> Business Profile `� Inspection Details <br /> TPID• I/ I O I I �. I I D / Inspection Type (Fill one) e <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation } <br /> Local L <br /> / If Referral,choose referral type(Fill one) <br /> Identifier: �/�� �p �/ („ptyAJ?LJ!j� Q CHP Q CIWMB Q Complaint Q Educational.Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> A�-T-b CA421- 3 q - I HAS <br /> Physical Address <br /> I 310 - W , uou i se Ave- <br /> Street <br /> veStreet <br /> !/��/r Inspection Date Q � � � �•- � © 8 <br /> FZI <br /> " State P Cod2J Time In Time Out _ <br /> Business Rep Title Q AM ( O AM <br /> Tlo PM '� � 0 PM <br /> -1"� pw�/�� A44 <br /> .t ` r -— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator @ Outdoor <br /> I O Q Closed Q Altered <br /> GPS Latitude �' I•; I I i Q Hauler Q Indoor <br /> _' 01 <br /> Q Truck <br /> --i-- -- - i - - --1— ,O <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Deater 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 IXT) <br /> Q O - - <br /> 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 /> Q Q Other: <br /> Comments /l'�L��•^/C_e'n/_ e�_�—L�-'Lt-S—d�•�_,_/_ " <br /> 204 <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> sls R p's natur Phone Number Inspector's Signature Phone Number <br /> �� M V 9r I j� j� 1 1 s2oe1 <br /> INSTRUCTIONS ON BACK Co�reCt: ncorrect: � X A ihlf P 'L E� �1�2 3 <br /> ■ <br /> y:C <br /> White Cop MB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />