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■ ==rrr Waste Tire Survey & Inspection Report Inspection R�)hd�t"Id�rt>W7 <br /> N: State of California <br /> CIWMB 581(New nage Survey Form - Page 1 -1 4 1 01 0 71 1 <br /> Calfromia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y �} r - [Kil <br /> Inspection Type (Fill one) <br /> Site Suj��R <br /> ffix: I `7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier ayt- yl cz't1( (rt 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /VI Inspected By Inspector <br /> I M N B EX-press <br /> Physical Address } j_ �t l� <br /> L _&Q 5 Vy jQ wll_}_-e f���i t t� <br /> Street © I o ( I <br /> v^O q t� € Inspection Date <br /> ay — State Z!P CodeTime In Time Out <br /> Business Rep [� Tiittlle(�s�� O AM O AM <br /> OX 1 ►Qml \ t_t u [1-1'm0PM m' 0 P <br /> —J Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTF-) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> L <br /> ( O 0 Closed 0 Altered <br /> GPS Latitude } I'-D—Li. 0 Hauler 0 indoor <br /> tJ 0 0 Inactive ®TruckLongitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply)TFIF <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other lCV4- :(YIIZr <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS �. <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle f <br /> 0 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date m ` LEI I 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 or EXT) <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 1 CIWMB Enforcement <br /> 0 0 '14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> —I– �? �' <br /> 4rzkA-&-P fir lova 1 YWJ a.AA JQ. 3,A4-'r, I _pa��.,`, (01ZSt <br /> ,��,t ts_ n sive _Q��)0rdrrne <br /> Inspection Form Included: t y <br /> Comments Included:411 - <br /> I Business Rep's Signature Phone Number In C's SI n tune Phone Number <br /> INSTRUCTIONS ON BACK orre <br /> Cct: correct:?j(j\ l � N AMP E: I 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />