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�82�2C4�5:2 <br /> ere. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CrWM fCagfoew Survey Form - Page 1 Il 1088392 <br /> CIWMB 781 thew nage y <br /> Cillfomla Integrated Waste Management Bond <br /> Part A-S_urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h /^ Inspection Type (Fill one) <br /> r6 <br /> Site Suffix: l oI ( 3 O r ®Routine Q Re-inspection Q Referral Q Observation <br /> Local — H Referral,choose referral type(Fill one) <br /> Identifier. Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ------ - <br /> Inspected By Inspector <br /> L Tra.c ill air I _ n D <br /> Physical Addrt�s w 0 [2�q <br /> - =1a, <br /> L\ ( _ j <br /> �3�03 �S 7}-,- kCCC///� I ��'��I���1666��` <br /> Street 5di <br /> >,9 Inspection Date [0—pa. <br /> ��� rte- ' TimeIn _ Time Out <br /> ciri ��— scare zr e , <br /> Business Rep Title —1 �� O AM �- O AM <br /> Hk•KGU1 O PM I _ O PM <br /> — —Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � '� Q 5 <br /> ®Active (1p Passenger ®Generator Q Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _. ...�_i• ....'.. ._ Q Inactive ®Truck - <br /> .. ---.0 <br /> Longitude - Q Planned ®OTR ®End-Use ®Container <br /> Business Type (Fill all that apply) <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 ®Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A HA-1,V1LI G AND MAN FEST REQUIREMENTS Q Notice Of Violation 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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days Required for NOV or RAM <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 /> Q Q Other: § <br /> Comments •Dpr,.{�,,� ���,c-,t,,,-,-/�'� S— h0�-P�.S— - <br /> �C� ►C,(./`^_''�"�-s-6.,�cr�P`-�r W_a5f-��_��G�: +'An�%v_�,��Lc <br /> r0 l'►ckctr�C_ v_ G�2— eS . e s_f Ir—al <br /> S vie- <br /> _Apra ' cis � da l qh,S - - -- <br /> Inspection Form Included:Q 1909 <br /> Comments Included:Q <br /> 8 sines.Reps Signa Phone Number Inspector's ignature __Phone Number <br /> - <br /> -INSTRUCTIONS ON BACK- Correct: Incorrect: E I K I A Ill P L E 1 -2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy LEA - ® ■ <br />