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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> ClWMB 7(teManag) Survey Form - Page 1 { 5 - 1 4 2 6 6 3 6 <br /> California Integrated Waste Management aoard <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business_Profile Inspection Details <br /> TPID- O C { I _ 0 Inspection Type (Fill one) <br /> Site Suffix: l 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Says ,)U � Cau( Q CHP Q CIWM5 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> s�1 ,7��9�� cv �yuaimteu�17 3 _ 1 r <br /> Physical Addres <br /> ll'�►c !F_ H-a31etLn Ave <br /> Inspectlon Date <br /> C <br /> Time In Time Out <br /> Business Rep Title 0 r1 D O AM (D AM <br /> 1 V O PM O PM <br /> Tim Cs�1 d ti�Q,I M �aad ,ti1cw,�-, <br /> Operational Status Tire Type f Business Role Storage Type <br /> ,1 (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) U <br /> ® Active i ®Passenger Generator Outdoor <br /> I <br /> Ci <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet m Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT ST,1TU4 <br /> V1 A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Vlglatlon Q ExEentilt�tt <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance DwtdlNte <br /> Q 1 Q PRC§42956-Registration/Decal in Vehicle �I�I <br /> Q ® 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Dote <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIW M6 <br /> Q Q (Required <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 10 1 ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMS Ellfpr teef r}f <br /> Q 11 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> n Campltance N>a�Yq(fy' tfpif., <br /> 0 Q Other: § L " (,'c- <br /> Comment6SaK fU0.p W" �Ot�Kfy �Itil,ri c-tiVorks Y&Y-t hoCcSe S' p0ad ~Z�in U Cute Cktc uieJ <br /> F-Ib04 0av+,&I . Wa51i_ -jjreS are S-fDrzd ;n S'e)paratit. Iv-, y0tk'4 , Waste *hv'es iavAe, <br /> JrOWI roCLa Si(f e_ deai1 -Vt8, S110_.-;�CF_'['Xrczk"f Meyl+vA,Cje 'MC6Wfe-y1qnC'e aflct <br /> Inspection Form Included: Qr L&q-30-7� Sp -�-97C 99C <br /> Comments Included: _7 lr(C� _ <br /> Business Rep's Signature Phone Number Spector' ignature Phone Number <br /> INSTRUJTMJCPN BACK Correct:* Incorrect: ( }-V{ JE XI A rJ P� L I Ei I t 1 213 I 62081 <br /> KB White Copy:CIWMB Yellow Copy:Operator Fink Copy:LEA <br />