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8227040193 <br /> Waste Tire Survey 8t: Inspection Repo Inspection Report Number ■ <br /> ;r <br /> State or181i'NewM04) Survey Form = Page 1 � 1 5. 1 .0 � 0 8 7 7 <br /> CIWMB 1g1(New nage <br /> Celitomle Integrated Waste Management Board. <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile'- Inspection Details <br /> TPID- Inspection I D r Inspection Type (Fill one) <br /> Site Suffix: O 1 ll 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localcc I If Referral,choose referral type(Fill one) <br /> Identifier:. I JAN J a A �.rl f9�J't�J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ° <br /> Inspected By Inspector <br /> �i,y5i� �+f-e t" TZ.a�.1s -r o,.1 13 C� - l 0 I 1 <br /> aµt_HAeo�►.�� <br /> I 4-?,6 LAL�antn_0� I <br /> Street <br /> Inspection Date <br /> L—T2A Gu l',4- 5'3_416 I <br /> City State ZIP Code Time In Time Out <br /> Business Rep 1 ,�Tiittl�l��e1 O AM O AM <br /> .J o,�l, / ✓Ct. y�y� . z"qO✓36 m m O PM m m O PM <br /> LL==�1 Operational Status Tire Type Business Role. Storage Type <br /> Tire Count Whole/PTE f l /'J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` ' °�I I' v_ 0 Active Q Passenger 0 Generator 0 Outdoor <br /> I Q Closed Q Altered <br /> GPS Latitude m- I I Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> Longitude - V Q'End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E_-�ri.,,xrsc;uf:i r STATUS <br /> JV A liAULING,AND.MANIF.ESiT4REQUIREMENTtS Q Not ce Of Violation Q Eztens'on <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q. Q PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying wilh.Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 10 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOV or FXn <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System.Requirements for Registered Waste Tire Haulers Q Ref rzed/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q. Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Viotat ons <br /> Q Q Other: §, <br /> Comments n <br /> 9 � KJ1dL(.�NE—._^!$�el�r�^'t—O'r-r—1�,o G�a'�.e--,t- ���'���'�p''`i►^'r'gnWO-4_ <br /> �L�►'L d.Wu-�( N O/V f���G."Ta-6yt S—D/Z�/�-G_C�t-NS—IV o (/-'�J✓- <br /> Inspection Form Included:Q <br /> Comments Included:Q— � � .}►aC ���"�'� 4401119 IL 1 <br /> Busi ss Re ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C► rrect: Ineorre¢t: I EIXI aI1HI P I. EI. 1112131 62081 <br /> `+ d <br /> ■ - White C y CIW Yellow Copy.Operator Pink Copy.LEA ® ■ <br />