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Waste Tire Survey & Inspection Report . Inspection Report Number <br /> State of California 1 7 0 9 <br /> CIWM618t(New04104} Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey ----- BLUE OR BLACK INK PEN <br /> Business Profile_ �1 (} ^(}'}r}�} Inspection Details <br /> TPID- ILI <br /> Inspection Type (Fill one) <br /> Site Suffix: 3 ly -2 `3 l / / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: E5 laak;,m C0,4�__ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name VInspected By Inspector <br /> Les <br /> Physical Address <br /> 10 Wo�w��eve, I �� <br /> Street ! !11 1 1 I FOT6 <br /> CA q�Z^5 ( Inspection Date IILL�_��VVJJIIII ,I,I II11 <br /> 1 0 AM <br /> City State ZIP Code Time In 0 AM Time Out <br /> Business Rep Title O PM 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude T I i _ �; 0 Hauler 0 Indoor <br /> 10 0 Inactive 0 Truck <br /> Longitude - ,! I I I I 0 Planned 0 OTR 0 End Use Container <br /> Business Type (Fill all that apply) <br /> It Nev Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Deafer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A7 HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date m , m <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 ort JCS <br /> 0 0 14 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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> L�0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsIn Compliance - No Violations <br /> Other: § <br /> Comments _ C _ <br /> cLt ase <br /> WAYI�OY��t�GtI�,ST <br /> Ih Voices ✓,12 _ A_ ,0^ --re TWO fi►Zt�r p ,- <br /> A7&L_CQi_ <br /> Inspection Form Included: a, ) �G} <br /> Comments Included: 0 — - J l <br /> Business Rep's Signature Phone Number In or' i ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: ( E X A M P L E 1 z 3 <br /> White Copy:'CIWMB Yellow Copy:Operator Pink Copy:LEA <br />