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l'Od 9e�'.V'9V 3�i�.67 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CFWM rCanfemla Survey Form - Pa e 1 I 1 - 108825 - - <br /> CeNMe 181(New nage \/ 9 <br /> Callfomla Integrated Waste Management Board J `�J' <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O I 5 - I O / Inspection Type (Fill one) <br /> Site Suffix: L•+ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: S9� C45 V N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Facility Name Inspected By Inspector <br /> L J Ti r-q- <br /> Physical Address <br /> l 201y S. <br /> Street <br /> / Inspection Date L <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 77 AM <br /> i---- I l --jI O AM <br /> OPM O PM <br /> _A4 (.lA . wl i _w164 0 <br /> _ Operational Status Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> to 0 Active 19 Passenger 0 Generator 10 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 ENFORCEM^NT STATUS <br /> V A HAULING AN I14 1 F E'S ITJ REQUIREMENTS <br /> ion <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of UiotatQ Extension <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 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 (Required for NOV or FXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifesl'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 IQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> // <br /> -�tin <br /> �f)!aW1— —/- �5 /r-`/Q-a_-.� <br /> A4..xe.f n4�. .4—4.16-t ✓Isa..J e 0 A/A F�i'ai'n+.O Z� <br /> Inspection Form Included:Q Q <br /> Comments lncluded:Q— bti�,_ <br /> Business Rep's '"niaiure Phone Number• Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK-- C«orrec : Ineorrect: E.' )(A M P QE, 1 2 3 <br /> ■ White Co y:CIW Yellow.Copy.Operator Pink Copy:LEA ® . <br /> rCopy <br />