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" o�3oao�oes� � <br /> Nene_ <br /> Waste Tire Survey & Inspection Report •Inspection.Report Number <br /> State of California <br /> CIWMB 18e ) Survey Form - Page 1 - 11 3 - 1 0 7 9 3 1 7 <br /> California Integrated WastastManagement <br /> Waste Management Board <br /> Sart A- Survev BLUE OR BLACK INK PEN <br /> Business Profile f Inspection Details <br /> TPID- t / I � I 3.171 � l I �I S I I S I( I � Inspection Type (Fill one) <br /> Site Suffix: { <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 1 Ya.-IL r�Q j� 1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> //� Inspected By Inspector <br /> ?a,�-r._ 7"�o��>,� 4-� r- I /1J�9-TA L�4 <br /> Physical Address D sua <br /> la-3 &—, <br /> treet <br /> Inspection Date D Q � I 2 / I l o I � I <br /> 6y State ZIP Code Time In ( Time Out <br /> Business Rep Title I I Q1 : 1 J I PAM <br /> M I /I ' I I TI O PM <br /> Awe <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> P13' <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3' <br /> Active ® Passenger ®Generator ®'Outdoor <br /> Latitude I t) j Q Closed Q Altered <br /> GPS I • I— I� Q Hauler Q Indoor <br /> - O Q Inactive Q Truck <br /> Longitude Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 10 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer S 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 ENFp.GENIE',•,STATUS <br /> RV"A�HAULING1*N.OWANIREQUIREMENij_ <br /> Q <br /> O O Noti le of Viol'tion Q Extension <br /> 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-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m111 <br /> Q Q 14 CCR§ 18459.1 -Tire Program 10 Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required or NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 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 ompliance - No Violations <br /> Q Q Other: § <br /> Comments �i(/C -. /' <z'L-t�l�"0�,� <br /> t% d <br /> ,S'�e 0"i&&J—_ PoP _/rte_ <br /> L4q �L, y► �,r� KJ 7'� I'u1 vc Gv�-I�t Terry I �3 !/.'t�✓�'� <br /> l <br /> Inspection Form Included: Q / <br /> Comments Included: <br /> Q siness Rep's Sig re Phone Number Inspector's Signaturr�e Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: nc reef: �XI�� I p II II I Z 13 I 62081 <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />