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tet Wgste Torre Survey � Ms ecfaon Re nrr� inspection Report Number <br /> ■ or y _ <br /> State California �,-�rn P(I�� � � e .1143508 <br /> CIWM6 181 Waste <br /> Survey Form tl ll �,.Page� . <br /> California Intograted Waste Management Board �i Il tl ll Gd - ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: S 1 ` C I P�I W <br /> `Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentifeOCHP OCIWMB OComplaint OEducational Visit O Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address L—1 <br /> q— - fl— <br /> T <br /> Street 1 1 b <br /> _ Inspection-Date <br /> -- r(L ��--���J Time In Time Out <br /> City State Z!P Code <br /> Business Rep Title �� G + {� <br /> t I I J 0 Q PM I v O PM <br /> Operational Status Tire-Type. Business Role --Storage Type <br /> Tire Count(Whole/PTE). (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all.that apply) <br /> r s Active Passenger S Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude j.:. i" Q Hauler Q Itidoor :.. <br /> —1-- -1 -� Q Inactive Q Truck <br /> 1 O <br /> LongitudeI , I i Q Planned Q'OTR O End-Use Q Container <br /> 1-71 <br /> i <br /> Business Type.(Fill all that apply) <br /> ® New Tire Dealer - Q Auto Repair .Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other i I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility- E.ryFORCEMENTt¢STATiIJS <br /> V A ; EN <br /> HAULING AND MA_NIFESTttREQUIREAilTSr <br /> " "� Q Notice Of Violation Q 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. Cbmpliance'Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> -'LTi:;`•. - <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required%for NOI%'br <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �'In:Comphance;:;= No:;Violations'- <br /> Q Q Other: § <br /> Comments <br /> - <br /> Inspection Form.Included: Q07 <br /> q ryry /(.(� <br /> Comments Included:®- - - ,.. '•-- - �-K 1- <br /> :-.. - - <br /> _, ;Rusin s .. .gpature= Phone.N.umtreY :Irisp oris Sigriatu- /Phone.:Nurriber. <br /> INSTRUCTIONS ON BACK Corr,, c .'� ncorrect` AIMI p I-L 1, � 62081 <br /> ■ White Copy: IW Yellow Copy:Operator Pink Copy:LEA ® . <br />