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ty== Waste Tire S 'ey & Inspection Repo-; Inspection Report,lumber <br /> x <br /> CHI <br /> " State of CaliforniaeTi CIWMB181(New04/04) Survey Form - Page 1 --�, 16 - 1 0' 91 7 9 <br /> .. California Integrated Waste Management Board - <br /> \ Part A- Survey <br /> BLUE h BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- / 1.3 �/5 ' _ Inspection Type (Fill one) �r <br /> Site Suffix: m ® Routine Q Re-inspection Q Referral Q Observation <br /> Local .� If Referral,choose referral type(Fill one) <br /> Identifier: - L A L4-I 'I (f-vIli , O CHP Q CIWMB Q Complaint Q Educational,Visit Q.,Other <br /> Business or Facility Name Inspected By Inspector <br /> r \ <br /> Physical Address <br /> 10-3 AAA _S1 <br /> Street O <br /> Inspection Date.m / <br /> on APel Time In t Time Out <br /> City State ZIP Cb <br /> Business Rep Title `f 0 AM 0 AM <br /> mm0PM m � 0 P <br /> L Re! Llq- it D LA) t)e yQ . I s 1 <br /> Operational Status Tire Type Business Role Storage.Type <br /> Tire Count(Whole/PTE) � �1�f I'2 � / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) ^ <br /> Active (J) Passenger Generator Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude m , 0 Hauler S�'indoor <br /> ` <br /> O -Inactive 0 Truck / <br /> Longitude - Q Planned Q OTR 0 Fid-Use Container <br /> I I T ----- -- - <br /> Business Type (Fill all that apply) — <br /> Q New Tire Dealer &Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Tire Derived Fuel <br /> 16 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM N STATUS <br /> VA ;,HAULING AICD-MANIFEST REQUIREMENTS <br /> 0O 0 - Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle \ <br /> O I O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0. 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> .0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Other: § <br /> Comments <br /> Ord <br /> Inspection Form Included: 0 <br /> 1 <br /> Comments Included: ---P� -- - - _ -..._-- - --p g - -- _ ... <br /> - _ 4 <br /> Business Rep's Signature Phone Number Ins ector's Si nature- Phone Number <br /> ---- - 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: ;_1 <br /> -V 1 . iii S I L I El 1112 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■- <br /> S �` <br />