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f- <br /> 0881 <br /> Waste Tire Survey & Inspection Report Inspection A0033 <br /> r„- <br /> epo umber <br /> State c1WM 181(CalifomW Survey Form - Page 1 1 1 - 1 0 7 9 .4.3 9 <br /> CIWMB 787(Naw OM04) <br /> califomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / .3 / 9 S Routine .0 Re-inspection 0 Referral 0 Observation <br /> Local c / If Referral,choose referral type(Fill one) <br /> Identifier: Gt .y1 0 CHP 0 CIWMB . 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> L p Inspection Date <br /> S <br /> City `o� Ste(ef,ZPC6de Time In Time Out <br /> Business Rep Title AM AM <br /> m' m O PM m'm O PM <br /> Operational Status Tire Type . Business Role Storage Type <br /> I r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; t I J <br /> Active .Passenger 4D Generator. ®Outdoor <br /> GPS Latitude <br /> O 0 Closed 0 Altered <br /> I 0 Hauler 0 Indoor <br /> `-� --—---� 0 Inactive 0 Truck <br /> O <br /> LongitudeI 1 1-1 I �—J 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) III ��LL�JI <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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / Ffl / M <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXt) <br /> 0 0 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/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 Generators 0 In Compliance- No Violations <br /> 101 0 1 Other: § <br /> Comments <br /> —N4�lc—trio f n cs. oGfjrz�Ss��Ree�[7o�r �'�ucd-2yJc —Ctu�s�.— <br /> _ or 3-lit circ. J tr>-r r ol&Sen�.�r a„c_i1Z2#' <br /> Inspection Form Included:0 v <br /> Comments Included:0 /—, _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect:�(!pl�J X a M P :L E ]j2T3 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />