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�8252�4��0> <br /> €e10_ 04 <br /> Waste Tire Survey & Inspection Report ' Inspection Report Number ■ <br /> gtataelCaY.,nt <br /> w. _ I1 - 1088197 <br /> C(WM8181(Ne047 ) <br /> california integrated Waste Management BOerE Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection i^1 O Inspection Type (Fill one) <br /> Site Suffix: I L4131315 ( 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /+ If Referral,choose referral type(Fill one) <br /> Identifier: Qo��tu 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physical Address - JliZ <br /> I 43550 - -o-� I <br /> Street <br /> � w Inspection Date <br /> �� ( �'��5 5 i Time In _ Time Out <br /> City State ZIP Coda <br /> Business Rep Title Q AM m m 0 AM <br /> Pm LH: <br /> Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one rnly) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' a Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 'O 0 Inactive 0 Truck <br /> Longitude planned OTR 0 End-Use 0 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 is Other PAJ0_e,j- comP <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT S1TjQTLU_S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements <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 (Required for NOV or FXn <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 I 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. §. ��f /�► <br /> Comments <br /> Inspection Form Included:0 a ZO 9 <br /> Comments Included:0 —_���Q� 0.�✓ 46 8 16- <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK •NI _ :� IneorrecteCX R hA P L E 1 _ 3 62081 - <br /> ■ <br /> Whit-7177 <br /> hite o y:CIWM Yellow Copy:Operator Pink Copy:,LEA ® ■ <br />