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o��zao�o8�s <br /> ue- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ril CrWM 181Cali(elnla Survey Form - Page 1 18 . 1 0 7 2 8 5 4 <br /> CNJMB 181 stew na0o <br /> California Integrated Waste Management Board — — <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ' <br /> TPID- / ^� /— - D I Inspection Type (Fill one) _ <br /> I Site Suffix: �O ®Routine Q Reinspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �A J�qq,,�N �jie y)__ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,7 _ Inspected By Inspector <br /> I—I��►d _owe_J� Tkuc.klNq_, LN C. I Q / I r I ' <br /> Physical Addiess V f - Ou <br /> ��'1 Da C�r,.,�Ja�ll q✓�. 1 <br /> Street Inspection Date O l z a S <br /> C656& o VI <br /> ity GA State IP C d Time In Time Out <br /> Business Rep Title O AM O AM <br /> +' O PM O PM <br /> Operational Status Tire Type ype 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) j <br /> 1 ° 10 Active Q Passenger (8 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeL_! JI,h — I I f Q Hauler Q Indoor <br /> ____ J ____ p Q inactive 0 Truck - <br /> Longitude Q Planned Q OTR Q End-Use p Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *.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 Q Other I <br /> Part B- Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORC-E .. ...... _ ....-- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Violation <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 <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> (Required <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days 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 Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for-Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: §, <br /> CommentsUoW N� G s ALT�d = <br /> 1 ase's t�i/SdYt �i/1G5��_ l7j�i1�l is�L� f r"ie <br /> _flQ.�/er/S�tvt�t,e %',2cS A2Gtt/rCcc1 Dh�•�e. Ale) (�ia/_ot�r_o�r� <br /> Inspection Form Included:Q - <br /> Comments Included:Q — <br /> Q <br /> Bu4ness a 's Signature Phone Number IPector's Signature Phone Number <br /> INSTRUCTIONS ON BACK CoIn, rrect: ) Q FE_FxjAjMjP[L1E1 1112131 <br /> 62081 <br /> ■ White opy.CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />