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07354050020 <br /> Waste Tire Survey & Inspection Report - inspection Report Number <br /> amtea�'"New Survey Form - Page 1 1 2 - 10 7 3 3 6 8 <br /> NS to o California <br /> euwl <br /> California Integrated Waste Management Beall <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - ) ! D (� O ;z1 _ KI <br /> 1 Inspection Type (Fill one) <br /> Site Suffix: ` f ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> j Identifier: , �(�(� `{'� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Bust ess or Facill NameLl <br /> f/�� J Inspected By Inspector <br /> I lIG(S-krl j2oaol �� r(rt)Q✓� L6Gl �C I I /� r— r <br /> Physical Address <br /> q,j q c) S usti� dol ' <br /> Street <br /> Inspection Date / � / r D / O <br /> City StateIPS Time In Time Out <br /> Business Rep Title O AM OAM <br /> evil :MOPM [IT O PM <br /> Of Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only)' (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r ®Active assenger ®.Generator 0 Outdoor <br /> - j O 0 Closed Altered <br /> GPS Latitude I I,j —� 0 Hauler 0 Indoor <br /> J—_- —��—I O 0 Inactive 0 Truck <br /> Longitude - ( i I I I I 1 I 0 Planned 0 OTR ®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 I <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-.Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 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-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXT) <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 0 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 0 Other: § F�,,e /�}7 - - ,r, 1 ' —bas <br /> /� ,//ten n <br /> Comments ' tt ir, •.�) S W Q. 'his _ `(�T I as tM0s� l�.C--`^—�'`C <br /> 4 0 �Ise o ry�aYu-��S�s haus .be: .. <br /> fig b p� S _ �es ` ave `1 Ce�t_a✓��—�v�`o <br /> Inspection Forth Included:0 A' <br /> Comments Included:® —- - <br /> siness Rep's Signature Phone Number Inspector" ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XAAhPLE z- 3 --- —62081_—_- __ - <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Capt'LFA <br />