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aQ��se��o7� <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rrt Survey Form - Pa e1 11 1 0 791 90 <br /> rr State of California <br /> CIWMB 181(New nags y g _ <br /> Cellforele IntegreteA Waste Management Board - <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile <br /> Inspection Details <br /> TPID- inspection Type (F <br /> ill one) <br /> Site Suffix: o Routine <br /> Q.Re-inspection Q Referral - Q Observation <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier J o ckg(A lln t rJ lt) 11 u — <br /> 5 4� ,1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I—__ �_ T►se S_O�"k+io-res 1 FTlo-T, <br /> Ph sical A-ddress y �K,f�s��a�L:,lccLs—J <br /> Street <br /> Inspection Date <br /> 'v+ocVAo'n GA 9�2d6J <br /> rty State QIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> OPM �'� 0 P <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE).' I pp <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' I 2'J O 0 Active Q Passenger 9 Generator 0 Outdoor <br /> it �0 Q Closed Q Altered <br /> GPS Latitude II 1 Q Inactive Truck <br /> Q Hauler Q Indoor <br /> L —I <br /> 0 <br /> Lon itude Q End-Use 40 Container <br /> 1 <br /> g - I -1 Q Planned Q OTR <br /> 1 17F] J_ <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer •Q Auto Repair Q Trucking Fleet p 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 4k Other L_Mpbi!e -Tim fV1_CeS <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 p 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 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 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 O 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 �O t.CT11 itZ l ns�C�l Ong armed - 1La,1'e4 CniL-701 U."i nG—wask new <br /> R!2'& C& ar uJas�e�ce.11c�►�l►no�-`C(TL'Shnm& he.en_ <br /> &r MewI -on1t2S���s�re9a►y e s <br /> No I caYt c-e m!__gAe d� <br /> Inspection Form Included: � ) <br /> Comments Included: <br /> XIB.sirlessp' <br /> — <br /> es Signature Phone Number Ins s Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr c : 62061 <br /> � ncorrect: PLE�(� �' EXAM ' f 23 <br /> ■ White Copy:BIW B Yellow Copy.Operator Pink Copy:LEA ® ■ <br />