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Waste Tire Survey & Inspection Report Inspection RI;NWit <br /> crr: cwma ial Jorn�a Survey rve Form - Page e 1 - j $ - 1 D 1 7 3 <br /> tr CIWMa 181(New 04104) y 9 <br /> ��Calaornia Integrated Waste Managemont Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> t TPID- D - / Inspection Type (Fill one) <br /> Site Suffix: Ld3]q 1@ Routine Q Re-inspection Q Referral Q Observation <br /> Local �M - ��� if Referral,choose referral type(Fitt one) <br /> Identifier: L lM Q CHPs5e,�LQ CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �{�/ 7 Inspected 8y Inspector <br /> Physical ddress LQ �� c �ss� 3 q - Ft-Fz-) F I <br /> I W �J r U� AV e , I �.J — <br /> Street Inspection Date O J 1 1 l <br /> City otale Z11- de Time In Time Out <br /> Business Rep Title IE <br /> O AM O AM <br /> T erl� ljf_ /I/1 `m O PM m'm O PM <br /> `f p �� �VL 1 ► ) -—J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) . }n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator 0 Outdoor <br /> r 1 O Q Closed Q Altered <br /> GPS Latitude �,I —k Q Hauler Q Indoor <br /> L O Q Inactive ®Truck <br /> Longitude - l� I Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) ffff <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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q © <br /> 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 (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — <br /> i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§16461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments D �� _ dal was <br /> tr-e* Sem ViC2 Q <br /> o S• ~�✓91 C'.LS VI 2W�-) 11 D <br /> 14 J �hQflt: e- 1 —gCv(v-g`I(o' (�Gt� t&cGCp <br /> Inspection Form included:® ya_00 <br /> Comments Included:Q <br /> Business ep's Signature Phone Number I to CtOl"tSibri.ture Phone Number <br /> INSTRUCTIONS ON BACK Correct-.10R}(t 10 Incorrect: � E rdt X A P L E 1 Z 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />