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07312040423 <br /> eu- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sta'°°"aII°mla SuF - P 1 1 3 - 10 7 3 5 5 9 <br /> CIWMB 181(New 04!04) rve Yorm ae <br /> callfornia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U ? inspection Type (Fill one) <br /> Site Suffix: f / 5- 3 2 c7 Z 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .�r t n Cyyrw/)' Q CHP Q CIWMB Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name UU Inspected By Inspector <br /> Physical Address � 9uf71CNl� <br /> Street Inspection Date <br /> City P. State ZIP Code Time In Time Out <br /> Business Rep Title t♦AMED <br /> 10 AM <br /> O w r1t r--._� •mJW PM m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I ' (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 17 •Active Q Passenger ®Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I I II I Q Inactive ®Truck Q Hauler Q Indoor <br /> O <br /> Longitude _ I l— Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4D Trucking Fleet Q Government Q Retreader 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC--EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q Q Q Extension <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 <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 EXT) <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 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 <br /> —�---�--�x_c�r.�..,�,1..—��+►��h—%<C:ZG—�ca�/—�.,.ro,•c.�-s avu�%•-7�i_D_# <br /> inspection Form Included: <br /> Comments Included:Q ` i6��b6z3 <br /> Busin ss Rep's gnatu a Phone Number Inspector's Signature Phone Number <br /> INSTRU ACKC rrect: ncorreet: E X A M P.L E 1 Z 3 62081 <br /> ■ White py CIW Yellow Copy Operator Pink Copy.LEA ® . <br />