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x..11.11-C_((-[-C,.,�. <br /> tr: Waste Tire Survey & Inspection Report <br /> Inspection R��i WAISA �3 <br /> CIWM8181(New 04104) Survey Form - Page 1 [�I 4 - .1 D 0 6 9 4_� <br /> CalHamia IntaBrat.d W.M.Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O O ( - O I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. alrL J D 0 CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Fac0ify Name - Inspected By Inspector <br /> AIrnal� e �� <br /> Physical Address V/� 3 _ <br /> L �`��s o lam/�-�►' �j-.x..C, 1-.+"t i - —— - <br /> Sheet <br /> !f1, Inspection Date <br /> t il� - Yo <br /> tate Z� Time In V Time Out <br /> 1 <br /> Business Rep Title 0AM O AM <br /> m 0 PM m OPM <br /> .�� Operational Status Tire Type Business Role Storage Type <br /> Tire Count <br /> �w a1e/PVTE); I nn (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t V O ®Active ®Passenger 0 Generator ®Outdoor <br /> f I I 10 0 Closed 0 Altered <br /> GPS Latitude I 1 � ®Hauler Q Indoor <br /> f O 0 Inactive 0 Truck <br /> Longitude - I TTi <br /> ,IT_J I 1 <br /> I 0Planned Q OTR ®End-Use ®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 /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ®Hauler 0 Agriculture 0 Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m / m <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention or Manifest Forms and Tire Trip Logs for 3 years. <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/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 1 0 1 Other: § <br /> Comments tt2 Irl S�2Gy� S tJfAf Ir,e��t _ -1�r P o l�t�— <br /> J�, _- {I��_•,,S A l�berl�rs iced_ r r t, d -tc✓ �S mrd►ten , , <br /> '� u Sj[aeJrlat S fpr w she fl-'e d <br /> CTL ► �+�c 2St3 V I Per Lau,-A /U' no CTL OLC ✓I_ <br /> Inspection Form Included:Q QU�> r' <br /> Comments Included:® � k:fV 333"710 <br /> Business Rep's Signature Phone Number I oes ig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect:X(j) q IIEIXIAIMIPILE[--FI-F273 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br />