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■ U 8 2 3 4 rt Numb) ■. <br /> *!IA_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> I 1 10881288:] <br /> CIWMe,6,lHew U<,U<, Survey Form - Page 1 <br /> callfomla lntegratetl Waste Management Boartl <br /> Part A.; BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - i <br /> - [�E <br /> Inspection Type (Fill one) <br /> Site Suffix: � 3 F:5Tr0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JOI.n 70CL It,(tn COursh' Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L,1-1.0.1 CW&rniq <br /> Physical Address <br /> ,_15ZI Uj. C.10r+er LAJ_aJu_ <br /> Street <br /> Inspection Date <br /> S{ackto n ___ CQ 952.,06 <br /> Crty State ZIP Code Time In Time Out <br /> Business Rep Title <br /> _ _ SPa.p _ [:E,O AM �: O AM <br /> $ _ Fle2rO PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> A A *Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ,•I Q Hauler Q Indoor <br /> Q Inactive Q Truck N/A <br /> Longitude - .' i !,I I Q Planned A OTRQ End-Use Q Container ' <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Other <br /> I - <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility KENFORCEMEN1T STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q 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 <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 FX!] <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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> _moou'}.n: - •on 1Aot►ned *bms <br /> aep-* 0C:6 am ar+ +ok&r% 7�6 tomes Ss�w ��nt_-t►te servic8,_.11Co�'lres <br /> �c►�n�ro�}o.�—cr s`�Core�an-sib. . All tyge—w YK a+earsrarAU(i 01N-3s1 - wTMS <br /> f <br /> shQ+aed-tlaa�vJilzo_�q�,,Za �t4e LLd_m ick_ ori-h�es_�- b <br /> Inspection Form Included:Q <br /> Comments Included: <br /> Business Rep' Signature Phone Number. In es Signatur Phone Number. <br /> - — 62081 <br /> ■ INSTRUCTIONS ON BACK 7G_d��IB <br /> ncorrect: E X A hh P :L E 1 2 3 1 ■ <br /> WhileYellow Copy:Operator Pink Copy.LEA <br />