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cre_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr SlateolCalifornia 0 <br /> Me 161 INSurvey Form - Page 1 I -5 - 1 Q 7 9 2 7 7 <br /> CIWew 6/04) <br /> califomia Integrated Waste Management Boartl <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: I 'I- I I -1 T 0l - O / 0 Routine 0 Re-irispection 0 Referral 0 Observation <br /> Local /^_ . H Referral,choose referral type(Fitt one) <br /> Identifier: ���/ v0�¢t t�A l�/ice- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Q9 U Inspected By Inspector <br /> C- <br /> Physical Addres�sl <br /> Street <br /> �pInspection Date <br /> C�/1t �t�!1Q52�0S_ <br /> city— State ZIP Time In Time Out <br /> Business Rep Title m' 0 PM m'm O PM <br /> F----- - _ __ <br /> Operational-Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> �7 <br /> r Active 0 Passenger Ill Generator 0 Outdoor <br /> l l I ! I O 0 Closed 0 Altered <br /> GPS Latitude I—I I•I i -_ I 0 Hauler 0 Indoor <br /> --TTT--��0 <br /> 0 Inactive I*Truck <br /> Longitude - '' I I i _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 Govemment 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 L� r(,({b. 1. <br /> Part B-Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> -- - <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violatio Q Extension <br /> 0 0 <br /> 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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB II <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for NOV or EXT) <br /> 0 O -- - - <br /> 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 C-ompliance - No Violations <br /> 0 0 Other: - <br /> Comments E7�SC�1/. �r�• //V t�p��/�+^� OYt /siy 6q G_.—`/ L All <br /> j�Gett� �e �dG+,..�2.�• Ltlro �u.CrflGf�s w�.(� T, <br /> - d;��,k,�s.�_ ,l/o _-�an�l�s� C�►�tur s�a r� <br /> aq <br /> Inspection Fonn Included:0 o e 6% 9�-3 <br /> Comments Included:0 T <br /> Busi ss Rep's Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co act: I •orrect: E A P E 1 2 <br /> ■ While Cop.CIW MB Yellow Copy.Operator Pink Copy.LEA ® . <br />