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= „ Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate o}Cegfunla Survey Form - Page 1 -I l 1 41 3 6 8 3 <br /> Cgmte 181(new 0U04) <br /> California Intagroted Waste Management aoartl <br /> Batt A-Survey BLUE OR gl AQ INK PEN <br /> Business Profile Inspection Details <br /> TPID- yy y I J Inspection Type (Fill one) LVJI�JUU W— <br /> Site Suffix: 1 J I ap 9 I / 1 l y I`i I RoutineQ Re-inspection P Q Referral Q Observation <br /> Local _,,I( If Referral,choose referral type(Fill one) <br /> Identifier: dSL 04 ��y c� QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> &22cr <br /> (Physical Address V Tz9 <br /> r l / 1 O I / I <br /> o25'ao lam•°�r -� I — — <br /> Street p i a l l D <br /> Inspection Date <br /> City State LIP Code Time In Time Out <br /> Business Rep Title e AM —� B AM <br /> fL2.�6� ZRcgv�c� �l_./_� 0 PM �,0 ��1f J 0 PM <br /> r/ 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 r0 Active �Passen Passenger <br /> 0 Generator 0 Outdoor <br /> D ' Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> - -0 Q inactive !Truck <br /> Longitude - Q Planned Q OTR LQ End-Use Q Container <br /> Business Type (Fill all that apply) j <br /> Q New Tire Dealer Q Auto Repair 4P 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 L <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STAT_US___ <br /> V i A HAULING AND MANIFEST REQUIREMENTS 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. Compliance Deadline <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 1114T] <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q I Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXn <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 Violations <br /> Q Q Other: § - <br /> Comments <br /> � I2o�cgl�' D��.-v«/ 7 �t�j-y_�r�� � }Li-4-�1 tom► �,.�t a� �� � <br /> -- <br /> (Dutucelc:'re2 }i^-Gl tis' <br /> Inspection Form Included:Q <br /> Comments Included: � ' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ q I I INSTRUCTIONS ON BACK Correct:• Incorrect:%&C/J EX A MIto P E1 1 I 1 2 1 3 1 62081� ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />