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07312040462 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> ar SnM5181(omla Survey Form - Page 1 1 5 - 1 0 7 3 5 4 4 <br /> CIWMB 101(New--g* <br /> Glifamla Integnled Waste ManagemaM Boats <br /> Part A-Survev BLUE OR BLACK.INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q .Z I O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Named•• U Inspected By Inspector <br /> Physical Addre�ss� I .3 ej — F/TCTI / <br /> a j s-o A,-� PIS Wim- I <br /> Street G <br /> Inspection Date <br /> lS3 0'1 I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM ELIO AM <br /> ®PM ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count[Whole/PTE) i. i e. y 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger 0 Generator ®Outdoor <br /> I 10 0 Closed 0 Altered <br /> GPS Latitude 1 I. Q Hauler Q Indoor <br /> � 0 Inactive Q Trude <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HA I G AND MA IE ST RE4 IREMENTS <br /> 0 O Notice Of Violation 0 Extension <br /> 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-RegistralioNDecal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 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 FXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 10 1 Other: § <br /> Comments <br /> ���b'la.���.S.�C.Ei-ins• OVA �t L2�.Ac� �+�._iCG<i�--fir/-S--i7-a? <br /> �1�,c�/ �_esu/—vra-olnucnt��'tfasStmT�rr��cEalC¢�rr Slu�,nsn_eGizcr�..s.�s..h� . <br /> Inspection Form Included:0 <br /> xDAN SO,v�.�S 3z�/ pa ,�.��� Y�� -ac za <br /> Comments Included:Q — <br /> Business Rep's Sign lure Phone Number -Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C res In rjr, JEWAIMIPILIE1 1112131 . <br /> . Whit Copy B Yellow Copy Operator Pink Copy.LEA ® ■ <br />