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int. <br /> Waste Tire Survey & Inspection Report inspection R�dAFM�Vtl.w <br /> C110M 1:'"r°r"' Survey Form - Page 1 16 10 1. 014 6 <br /> Cwuaat tN..OUN) <br /> Callfomla Int.grataC M.Mana9— eatud <br /> Part A-Survey_..-- - __- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - r 11 E-11 <br /> Inspection Type (Fill one) <br /> Site Suffix: ( .Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physloal Add're7oa =n 'fes Co���e��l 3 q I o L���uua�e i <br /> Si 51 a c�Fic it-A f o _ <br /> , Street ^ r MG '7 Inspection Date <br /> City <br /> —"- -" J- relod Time In Time Out <br /> Business Rep0 AM 0 AM <br /> Tide m•m O PM ELI: <br /> O PM <br /> t•"-Z- 00 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE) r , <br /> ®Active ®Passenger ®Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude � I I I Q Hauler Q Indoor <br /> W � �-�H--7! Q Inactive Q Truck <br /> Longitude - I 1 I O Q Planned Q OTR Q End-Use Q container <br /> Business Type (Fill all that apply) 1111 l l <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Denved 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 ®Other C011 _J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility Q1F1WR9EM NT STATUS <br /> V !—A ',,HAULING AND MANIFEST 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 Data m /m / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (RequiredW NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 %tis GiQ.Ie, hlS�Pr� <br /> vdj&_s�locoV Ove_fa.ufie <br /> 4ry � o 7,Ye 5 Co s' _ I I(RA-4_ a►^2 Cb <br /> ,Inspection Form Included: <br /> Comments Included: <br /> i _ . _ <br /> sine ep's Signature Phone Number 1 or's nature Phone Number <br /> - �( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(�l�J EXAM.P L E 1 2 3 ® ■ <br /> ■ While Ccoy:CIW M8 Yftik,w Copy y-Operator Pink Copy.LFA <br />