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Waste Tire Survey & Inspection Report inspection Rep rt im$0 r ■ <br /> �r ei <br /> State ai California <br /> CIWMB 181(New0 " Survey Form - Page 1 1 4 10 13 1 7 <br /> calllo is Integrated Waste Management Board <br /> - <br /> Part A Survey BLUE_OR BLACK INK PEN, <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> site Suffix: [I3=6y 6 S ' - 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�/t t�t)Q�K Gi h t�lj�Gvc 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6� Inspected By Inspector <br /> I Le QAtio &j ,r,i_,�.t 13 9 - d l , SL1,8,807A11 /� <br /> Physical Address 7A11Imo+✓4 <br /> Zvi /Ue <br /> street 7 <br /> b Inspection Date f <br /> Time In Time Out <br /> City Mate Zipode <br /> Business Rep Title OAM O AM <br /> A, /;V,2" M�m0PM Ell QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> l <br /> Tire Count(Whole/PTE)' Q (Fill one only) (Fill all that apply) ,(Fill all that apply) (Fill all that apply) <br /> I IoZ <br /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> [` .I j IW I I �O 0 Closed 0 Altered <br /> GPS O <br /> Hauler Indoor <br /> Latitude I I <br /> _1_70 <br /> I I O 0 Inactive 0 Truck <br /> Longitude — I I ,I ± 1 I I 0 Planned 0 OTR 0 End-Use 0 Container <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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 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� / ! M107 <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F]CT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 Generators0 In Compliance - No Violations <br /> 0 0 Other: § ,/� J <br /> Comments <br /> / - .K-l�bt?�i'b�Z COKl� }Y�! C� 44fe 14-4-C <br /> f ,,or�NS gn Pk e Y.Z 9 3-3 <br /> �Q[,r,G,1'S -- Fac►.iLi" %j' .?� `fZcd r1ou� b G6+s ate` cyr <br /> Inspection Form Included:007 <br /> // Y <br /> Comments Included:® ' <br /> Business Rep' Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK I Correct:0 Incorrect: I EIXI AIMAIMI P I COE 112 3 © ■ <br /> White Copy.CIWMB Yellow Copy-.Operator P%nk Copy.LEA <br />