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VOL 91. 535 <br /> O .tateef..111-1. . <br /> Waste Tire Survey & Inspection Report Inspection Report Number(N.- Surve Form - Pa e 11088262 <br /> cnvine tet(Naw oataal [� <br /> California IntegreteA Waste Management Beartl g <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 p 0 3 I D / 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: � J O q 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name C/ — <br /> �y_ 7L O>h n Inspected By Inspector <br /> •I C� 1t°V V p�� I q <br /> Physical Address ( - F/ O A/�i4.Q -� <br /> Ave I <br /> Street Q ,tq <br /> Inspection Date <br /> �� NIAnITf GA Ci4_ 5�3&. 1 <br /> City State ZIP Coca• Time In Time Out <br /> Business Rep Titler- <br /> -� i QAM I I I 0 A <br /> O PM I I Q PM <br /> �- <br /> - Operational Status Tire Type Business Role Storage Type <br /> i <br /> Tire Count(Whole/PTE) <br /> (Fill one only) ..(Fill.all that apply) ..(Fill all that apply) (Fill all that apply)8 <br /> r •Active Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � � 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude I I I - 0 <br /> •, I 0 Planned 0 OTR <br /> End-Use 0 Container <br /> Buslness 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 1 } <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENPOR_C-EMENT STATiUS <br /> V A !HAULING AND MANIFMITIR <br /> EEQUIREMENTS <br /> Q Notice Of Violation Q 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 Entitles Complying with Manifesting Requirements Date IE <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(or NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/C-IWMB 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 /> 1010 Other: § <br /> Comments <br /> `rWE1•r.!<.•—�Il S�_t.t.��"av� QYr /i�•�-� �a��.. � <br /> •4w.0- <br /> Inspection Form Included:Q <br /> Comments Included:0 . . — <br /> Business �S�iqtu�rPhne Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK JE.jXjAjMjP1,L K <br /> [1[213- <br /> 2 3 62081 <br /> ■ White Cop.CIWM Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />