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T ' 1�Q,�j <br /> Waste Tire Survey & Inspection Report Inspection R���rt'NII111 <br /> m <br /> scare or caorornia <br /> ctwM8ta1(No.M04) Survey Form - Page 1 i 6 - 1 01 0.6 9 6 <br /> ealltomta Integratod Waeto Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details f <br /> TPID- p 1 O O Inspection Type (Fill one) <br /> Site Suffix: ! M g / 3 - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: Ljoc1-t2 cfj'j,(,4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility"""N����amm�e l/ Inspected By Inspector <br /> Physical )Ad�}dress [a <br /> L 10x1 So SlVo Vi, S+. I <br /> Street /n <br /> \( � �'5120+(! Inspection Date <br /> City y —State Zip Co e I Time In TimeOut <br /> Business Reprn� Title ()AM O AM <br /> ,''rllla,rce�I n V �Gtr+rCt.A. �0 PM O PM <br /> --- T' Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) . �, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' + � i"�k�' <br /> I (P Active Q Passenger ®Generator @ Outdoor <br /> Latitude <br /> 1 1D Q Closed Q Altered <br /> GP$ I Q Hauler Q Indoor <br /> D Q Inactive •Truck <br /> Longitude - 1-1-TTITF—F—F, Q Planned Q OTR Q End-Use 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 Lea a /see- <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other ( LW"y Y4 1C-Q c <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A ;HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> —-- <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/DecalposE in Vehicle m m m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> (D Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other. § c1 <br /> Comments U <br /> h�Lv — tom 3889 hvvy 9q �ron-fa9e Rot 41d TP)b-A /3'?9208-b► �. Alea <br /> 7 I '� QSSi �1 S ii5 aC�l t _k4st s - S 'frtacfei S fn <br /> viCeS I e as2d �Yatilers. 1 bS ` .r✓`C.Q S <br /> Inspection Form Included:Q 2-0qj <br /> /7y <br /> Comments included: ® - <br /> - __--- Business Rep's Signatur hone Nu� ectot 4Si nature AAA <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(�l�J I P X R M L 3 1 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA © . <br />