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Waste. Tire Survey & Inspection Report Inspection RepoltNumber ■ <br /> _ <br /> stat°°f Ca"'°`nia Survey Form - Page 1 [ 1 3 - 1 0 7 9 1 8 41 <br /> CIWMB 181(New 04104) <br /> Jelif. Intograted Waste Management Boartl - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: f J�q fi 3 a q D •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L&t - 'tj C VN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �' <br /> Physical Address i 43 9 / 0 l I-I Lwin <br /> Street S �— <br /> Inspection Date <br /> rro c!c Tom_ , GA 95�2���� <br /> City State Zip Code- Time In Time Out. <br /> Business Rep Title O AM 0 AM <br /> Lr�O PM <br /> ELI:m 0PM <br /> -'-----J <br /> Operational Status. Tire <br /> I p Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r r ! <br /> Active Passenger 0 Generator 0 Outdoor <br /> r <br /> Latitude O 0 Closed 0 Altered <br /> GPS I� _I•L_I I 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude I� D 0 End-Use 0 Container <br /> I 0 Planned 0 OTR <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 /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m/m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)M <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> --------------- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 Other: § t T <br /> Comments gOO77_`,1FI_���Q .A-b—O_�/N/J 6.�C• /�1_/rs / (.I�j �je< / <br /> -���'jh-oYl—T-iGes�iS /?r_c!__ice /'ems�S _ _ t�7�i%2•� �7�t�t..,P'i�W.f�e37 <br /> � r c/ <br /> e/ L s pig. Ad V"o/ _cry/. O_2— __��f ri-s 0 7r4� <br /> F <br /> Inspection Form Included:0 <br /> .r.i� -Al2968 '74,13 <br /> Comments Included:0 - <br /> Business R at re her Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: I EJJXJ A Mj P L E 2 F2F3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />