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rr`a�9ay01iL <br /> ■ CtA: <br /> Waste Tire Survey &Inspection Report Inspection Report Number <br /> " <br /> CIWMS `. c'tgem� Survey Form - Page 1 1 6 - 10 7 3 5 7 :81 <br /> B 1B7(New 04(06) <br /> California Integrated Waste Management 00 rd <br /> Part A-=e BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 8 B / Inspection.Type (Fill one) <br /> Site Suffix: 1111 , O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier:„ i ppp w,V% _�. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or/F�a�ility Name J n `—�""" Inspected By Inspector <br /> OV - <br /> Physical Address GE EJZ] ^ . <br /> I Street ��� N• lJN i.0=h�`�� I <br /> Inspection Date Q m O <br /> I S*ocv— —CA �1SZbs I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ®PM ®PM <br /> — <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> J)P�j. ®Active ®Passenger. (6 Generator Q Outdoor, <br /> Latitude Q Closed Q Altered <br /> � GP$ Q Hauler. Q Indoor <br /> 1 O Q Inactive Q Truck <br /> Longitude w Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) <br /> 0-New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader - Q Dismantler Q Tire Derived Fuel <br /> xUsed Tire Dealer ®Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 1 I <br /> Part B-.Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STAT1U_S <br /> V A AULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 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 <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 FXT) <br /> Q # -- —-- <br /> 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 Q Referred t 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 <br /> 6.n 41_Y <br /> _C({ey.1_!^07- /--^ —�•l—f--y-•�.JGylB/ - <br /> LLYt it a A _ <br /> �jL—.[ILf.(.Li /q01h�/!� G��,�� Q •/9.A/Q�^4 QY !�/- G�A/! <br /> Inspection Form Included:Q k r/ KMf i /_�n/-0" �Comments Incuded:Q re Phon�eeNMltnkfc/ {j jou —- Pfh�o'tenje�4Number— <br /> b <br /> erBusiKessRe ' Sa ' r' <br /> ---- ---- ----—--- ---- <br /> • 7` 62081 <br /> INSTRUCTIONS ON BACK 1EjXjAjMjPLjEj 111213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator -Pink Copy:LEA ® ■ <br />