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G�g6�rl�UJ(� <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateCalifornia 9 0 1 <br /> CIWMB 187 thaw e4/84) <br /> California Integrated Waste Management Board Survey Form - Page 1 LI 2 - 1 0 7 9 2 <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- LiF_0__ Inspection Type (Fill one). <br /> Site Suffix: L t 5—i�� y 1 •Routine Q Re inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> T <br /> .Identifier: `)cA .J oaq. l(1 C o ,(*,,V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L_e,h�tc�kee '-fires_- tuheel5� _ <br /> ' Physical Address <br /> LKr i:si_�Qn Lu_c�s� <br /> L_� <br /> Street <br /> p G +� Inspection Date •O � / Q Q / Q 8 <br /> �Q A 1 – --CA---`_6 `oJ Time In Time Out <br /> City State LIP Cude <br /> Business Rep Title I I:T� O AM O AM <br /> _chart Knead `Rebowx J, Q wrue'I•.. I -I O PM '{ i O PM <br /> Operational.Status Tire Type Business Role Storage Type <br /> Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count <br /> ( , S •Active I.Passenger •Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i � I i Q Hauler Q Indoor <br /> _ t - —t0 Q Inactive Q Truck <br /> Longitude _ j i i Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> •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 Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation O 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 O 14 CCR§18459 -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 O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I*In Compliance - No Violations <br /> O • Other: §J_ CC9. f335'f - s+o�g.ce W0,5% -fires o1a d (' <br /> Comments T R,C� CJL4 01/ ' O Q <br /> ROt> 'i R2 1n6 C"t t eft r' Or M '115 - ra a—�_tlO_w_t l <br /> i „ <br /> } ��loorst, rrcac�L�-y��tP.s_P_n-d_111a�i_re�ar�.a�ste •-►-ire—pick-u-p <br /> CTLs r � <br /> Inspection Form Included:0 <br /> Comments Included: '1\ < Y `3 <br /> Business Rep's Signature Phone Number I9 p ctor's Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrec Incorrect: (� X .AMP �, 1 2 3 <br /> ■ Whit Copy.CIW Yellow Copy.Operator Pink Copy.LFA ® ■ <br />