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07312040429 <br /> =U_=r. Waste Tire Survey & Inspection Report Inspection Report Number . ■ <br /> n <br /> CJWM8 "°�'a Survey Form - Page 1 1 2 - 10 7 3 5 5 8 <br /> sI 191(Naw WI04) Y <br /> co ifomla Mtegmted Waste Management aoaM <br /> Part A-Su ee BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l 3 (0 131-2- 1 <br /> ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� - � Cwun.!-may Q CHP. Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> i�Sty C—A 15%41. / <br /> -_— stale Z CoTe Time In Time Out <br /> Business Rep Title O AM Q AM <br /> m®PM m ®PM <br /> i Operational Status Tire Type Business Role Storage Type . <br /> Tire Count(Whole/PTE) - ( (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' I z I S is Active Q Passenger ®Generator ®Outdoor <br /> 0 <br /> Q Closed. Q Altered <br /> Latitude I I__J( II <br /> _- {- . IIi <br /> GPS Lam .LJ. I IJ Q Hauler Q Indoor <br /> r O Q Inactive ®Truck <br /> Longitude - 1 I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <br /> Q New Tire Dealer Q Auto Repair Q 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility MENFORCEMENT STATUS _ <br /> V A HAULING AND MANI 'EST REQUIREMENTS <br /> Q Q io <br /> Q Notice Of Violatn 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§10459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§10459.2.1-Submittal of Comprehensive Trip Logs within 90 days ( equired!or NOV or DC7) <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/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 /> 1010 Other: § <br /> Comments 1r <br /> F< �rr►a—�/r�ttuL�r• �tN f o,Gs div ���L��+"`�^ <br /> �ot &t. <br /> �i.voils—tgzHc�—lfzc�teL�vr,�/�cn-2c�c�Nyyc:.�.rc� 4c�S�/_t/_c Via��h�l <br /> Inspection Form Included:Q <br /> X 04 7-_7-,// <br /> Comments Included: �C�u T �'� ^ <br /> Q Busine s Rep's Signaturdf Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [PILIE1 111213 62081 <br /> ■ W ite Copy:CIW Yellow Copy Operator Pink Copy LEA ® ■ <br />