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08157050019 <br /> i Waste Tire Survey & Inspection Report(_inspection Report Number <br /> UP5n""`'Wamla Survey Form - Page 1 1 5 1 0 7 3 4 61 <br /> C'MMa 181(Naw 04M) <br /> c,Surlf�v,iw�•awaae.we,s.m.mea,rd — BLUE OR BLACK.INK PEN <br /> Part A-Surve <br /> Business Profile r Inspection Details <br /> TPID- I O Q ' Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local San If Referral,choose referral type(Fill one) <br /> Identifier: 69,q ..on \/t9U�1t�l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> PhyL_Arnex_�can Se.i_sr L� I _ I O 1 �K_r_tstln LuCc_15-1 <br /> elcal Addre88 3 � <br /> I.38_y-j Disk Geek ` r- - , <br /> Street <br /> Inspection Date <br /> city <br /> S-3 C)CV_-an__ C_A 9-3ta�e 5515"J Time In Time Out <br /> Business Rep Title O AM O AM <br /> + <br /> 1-1-1 �0PM ' OPM <br /> Tco E-clel-er Se - -- ..-- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r 1 I 0 Active Q Passenger a Generator •Outdoor <br /> ---�0 Q Closed Q Altered <br /> GPS Latitude -�. i i I Q Hauler Q Indoor <br /> J__L_j Q Inactive Truck <br /> Q Tk <br /> =--t- -IO Q <br /> Longitude - i I I •I I I Q Planned 0 OTR End-Use Q Container <br /> Business Type (Fill all that appy) <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 Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder a Other i � � Ser,.\ce- �g5 <br /> 1 �--1S, 1Y <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility MENFMAREMEM S US <br /> QQ Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co pliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date m 7 / m I m <br /> Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days ( equtr for NOV or EXT) <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 efer e 1 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 - tQ Violations <br /> Q Q Other. § <br /> Comments Las <br /> �2���1 �q' <br /> An 01 • i s v�-Vck i vsp-- J1�1�5a� �r,�1EC-0— <br /> �r -- se_r . - L Fact +►���,urt � Q� <br /> cox —' —u ".3QsiCe>�.—'C,re �no.ri��es�s_rnu� e <br /> Inspection Form Included:Q J�(� 6S <br /> f.` <br /> Comments Included: + - - - `�Q _31 <br /> �� <br /> Business a Si na ure Phone Number I ors igna r Phone Number <br /> INSTRUCTIONS ON BACKA M P L E 1 2131 62161 <br /> — AXI■ W hila C py.CIW Yellow Copy:Operator Pink Copy LFA ® ■ <br />