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08010040185 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slata of California <br /> 'IWMa,g„Ne.gau4, Survey Form - Page 1. 11 . 10 7 3 5 4 0 <br /> California Integrated Waste Management 9oard <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 ( O Inspection Type (Fill one) <br /> Site Suffix: 7 13 1 $ I - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier. ,0. .w Q CHP Q CIWMB' Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I .S,W(fos . I—rtK le - ( I r LFtw�awaC� <br /> Physical Address 0 <br /> I i Zo d 0 f._!✓.leu'}=�=� I <br /> Street <br /> Inspection Date <br /> City � State�-ZII� Time In Time Out T1 <br /> Business Rep Title O AM O AM <br /> :FTI®PM ®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) f I f p <br /> ®Active Q Passenger. ®Generator ®Outdoor <br /> If( �lI O Q Closed Q Altered <br /> GPS Latitude W,� I I I� Q Hauler Q Indoor <br /> Q inactive ®Truck <br /> V <br /> Longitude - — -- — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer- Q'Auto Repair ®Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> . . <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STrAiT1U_S <br /> VA A�IM01NGYAND MANIFEST REQUIREMENiTrS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Uf Violation Extension <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 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 lorNOV or FXn <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 I .1WMB 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 /� e <br /> �Q Wa Sic JrifS 2_St�ryr�J� �071/rt i�'rli/ ��l�iG���Z�tyJ-�1.12J� /-�CC/��t-f4yt/�!YS�✓—C1' [d'1St_'L�-� <br /> /v0 ✓PUltt./�+_cry.f <br /> Inspection Form Included:Q X <br /> Comments Included:Q ✓ ���8'OL Z <br /> Business Rep's Signature Phone Number • Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect- IEIXIAIMIPI,LIEI1112131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />