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073b2040451 <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> s�`°°``°"IN - 1 5 . 1 0 7 3 5 2 8 <br /> cIWMBt61(Newture�l Survey Form Page 1 <br /> Califomla Integrated Wasl°Management 6oaN <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- u ,,/I r1 � D / Inspection Type (Fill one) <br /> Site Suffix: 7 13 I i - ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�0C' ,.� C�y.��+� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busine�s/s or Facility Name U Inspected By Inspector <br /> �l ks°l1. �,X Oy` k-r'hLt#'1 avu.�Q �r� I G <br /> Physical Address 3 / F/To <br /> 37:30 <br /> Street <br /> Inspection Date <br /> C1Sz1 � I <br /> City State ZIP CodeTime In Time Out <br /> Business Rep Title 0 AM <br /> m'S" m [I] <br /> ®PM <br /> L�a``"e Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I j (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r i ®Active 0 Passenger 0 Generator ®Outdoor <br /> I I0 0 Closed 0 Altered <br /> GPS Latitude ��_ J-� J_ IJ0 Hauler 0 <br /> III _1 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - I I J I� 0 Planned 0 OTR 0 End-Use 10 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility MENFORCEMENT STATUS <br /> V HAULING AND MANIFEST NTSIIIIIIIIIIIIIIIIIIII <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Eompllance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 (Req Iced for NOV or[yXTJ <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. § <br /> Comments <br /> .—nup_er�-i-�----/�7�Zi.ls—/aL4,t.�• �e�._�r;c� docs—���ru��_ <br /> —�!S��trLY✓�-rX'1 �J�- y<ir[.--pcuhs�r�+� HAf �cc_I�—O_/�d�-✓-✓-tom.'n Y�_�Jlirt <br /> -/1�-7S Kr/oil . __ Pn—Si/c�crr. {✓s_`Lu-�z. / 1.xtu/ c L.�r/1�t— `� ----_ A-/1 <br /> —r `_Q <br /> Inspection Form Included:0 <br /> Comments Included:03 <br /> spector's <br /> 0162 <br /> Business Rep's Signature _ Phone Number InSignature Phone Number <br /> �■ <br /> INSTRUCTIONS ON BACK -o ct: Incorrect. IlM X P L EI 1112131 62081 <br /> ■ While C py:CIW Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> i _ , <br />