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08017040716 <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> State o'f CfWMB`1(N la Survey Form Page 1 1 7 - 10 7 3 3 8 0 <br /> CIWMB 161(Naw W6t). <br /> "Ifomla Integrated Waste Management avant <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ' Inspection Type (Fill one) { <br /> Site Suffix: 'J ( / / ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: QCHP QCIWMBQCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �Atk� Trey L <br /> Physical F3E <br /> - I � � { j-amh , t/��1 V-��Da C& D-iXex) .S+. , <br /> Street ^ <br /> ��p n aC 7,0Inspection Date `. ✓J 'g ) O 1 <br /> If State ode Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Tile m'FTI O PM 'm O PM <br /> i <br /> Operational Status Tiro Type Business Rola Storage Type. .. <br /> I 22 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Wh01@IPTE) <br /> ' r t�1 -!.f Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude I O ('..I Closed Q Altered <br /> GPs �•"—�—I Q Hauler Q Indoor <br /> C_—I <br /> rr O ®Inactive Q Truck <br /> Longitude - I� I- M- --- <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) LLL <br /> Q New Tire Dealer . Q Auto Repair Q Trucking Fleet . Q Government Q Relreader 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 <br /> Part B-.Inspection of Waste.Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STAT S <br /> A HAULI G I -S RED 1 E - <br /> QNotice Of Violation Q Extension <br /> Q Q 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§1B459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> Q 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 (Requr ed for NOV or F�CTJ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ------ - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1(3IWM BIKEnforcement <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 Gompliance - No Violations <br /> Q 1 Q 1 Other: § (� L T� <br /> Comments I h an •�,� tr Q tl f7J�-f !II fir- a apd a YFL <br /> rtoA- '' alLVt�— l`f o►'+ i�cc.Fo� v-c a zo9 5'lo$-Y7 <br /> 3 jargf. Mires %Ft-on . /fir. f d ckj is a�Zti�►p � Se til �,►'er <br /> f� !o� UyAdor. Nlam� sq hm CgSclk. <br /> Inspection Form Included: <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Ins a"SIn Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> EXR1 '23 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />