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08206040140 <br /> Waste Tire.Survey & Inspection Report Inspection Report Number <br /> r Stab&calff la - ■ <br /> CIWM51a1(Newe1e) Survey Form - Page-1 1 6 - 10 7 9 2 4 5 <br /> cafNomia Integrated Waste Management Boats <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 9 © ' Inspection Type (Fill one) <br /> SPI -X: 8 Q Routine Q Reinspection Q Referral •Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: J^ y,N V��k Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . <br /> Inspected By Inspector <br /> L_(U <br /> Physical Address 1�i�11-,_L L G 1 3 9 - 1 0 / I�,�.�I +-���w�r► <br /> L—j_fo3_5_t S . ►,d.�_k,i_h_le�.i—A�e� <br /> Street ' <br /> crt- Inspection Date <br /> t Stat zi Time In Time Out <br /> Business Rep, Title LLI'm O0 AM 0 AM <br /> PM m'm O PM ' <br /> I Operational Status Tire Type Business Rale Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill alt that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger •Generator a Outdoor <br /> Latitude I I I �I O Q Closed Q Altered <br /> GPS l_ I _ I � Q Hauler Q indoor <br /> l ( �O Q Inactive 0 Truck <br /> Longitude - -J•I Q Planned OTR Q End-Use Q Container <br /> Business Type. (Fill all that apply)' l <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 f♦Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORC- MENT STATUS_ <br /> A A AN ANIF-ST REQ 1 M Q Notice CYViolation Q Extension <br /> Q Q 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-RegistraliorVDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 f r NOV or EY <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 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 - -N Violations <br /> 1010 Other: § <br /> Comments <br /> 0�se�✓�i_b.,a—!�ecll�atJ ad's—t�a�e • ate{_ollora_ia�t9._.�kiLs <br /> 7t%sau_!, trse t2 M75 .4s A�r'�—►r �e.i�0 <br /> _L11AA-1- N-AIS)-1_A- 54 1 f c--J ea. AL Jf a/a,-lr`Y'0,J_S_8_1R_ 6W_Ctr__w�Eo__ <br /> Inspection Form Included:Q <br /> Comments Included:Q- =u+v 310 a�til '� 46 <br /> Bu lgnature Phone Number Inspector's S gni ature Phone Number <br /> INSTRUCTIONS ON BACK ro or ect. X R P 1 .2 3 62061 <br /> E IM <br /> ■ White py CIWI Yellow Copy.Operator Pink Copy:LEA <br />