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08136040026 <br /> _: Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State afcalAomia04!04) Survey Form - Page 1 i' 8 - 1 01 0 8 71 <br /> CB 181(New <br /> Califomia IntegONMrMted Waste Management Boats <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 111.5 <br /> 15 `17 ( //I , I - a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: - OQAr4.�io 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name d -- <br /> n Inspected By Inspector <br /> I �- Ui,, 1 /d�f'1rtn 9 <br /> Physical Address _,Q <br /> Street �1�1 <br /> 953301 <br /> 5330 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title / O AM' O AM <br /> 0 PM m m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE): <br /> •Active 0 Passenger •Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude I � 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - i I L I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> i <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility ENFORCEMENT S,LTATUS <br /> t�V `GAJHA_U.LING ANDUMANIFE546REQUIREMENTS <br /> 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms'and Tire Trip Logs within 90 days (Required for NOV or FX>7 <br /> 0 014 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers. 0 Referred f C-IWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-ompliance - No Violations <br /> 0_ 0 Other: § <br /> Comments <br /> Inspection Form Included:0 �0 <br /> Comments <br /> �u3ltt�ss R s Signa re Phone Number inspector's Signature Phone Number <br /> • IEIXIAIMI f l I' 111:2131 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. P ;L E <br /> ■ - White Copy:CIWMB Yellow Copy Operator Pink Copy LEA ■ <br />