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08OS20S0011 <br /> Waste Tire-Survey'& Inspecti.on Report .; Inspection.Report Number. <br /> rr Stats of California <br /> CIWIYBI8,INaw OM04) Survey Form--:Page 1.: l_ 3- 1010 5 9- 41 <br /> California IntegrateA waste 1101 —rd,BearO . <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) , C ? - O f Inspection Type (Fill one) <br /> Site Suffix: r oL Q J I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,.choose referral-type(Fill one) <br /> Identifier: 'JF Q CHP Q CIWMB ' Q Complaint Q Educational Visit.Q Other <br /> Business or Facility.Name Inspected By Inspector <br /> P,'c� <br /> Physical Address <br /> CQAk <br /> Street <br /> Inspection Date pL O <br /> t <br /> city State ZIP Code(� I Time In Time Out <br /> Business Rep Title O AM O AM <br /> MOPM m�m 0 P <br /> Operebonal Status Tire Type Business Role Storage Type <br /> Ind G t� C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> il�`J ®Active ®Passenger .®Generator ®Outdoor <br /> O Q Closed. Q Altered <br /> GPS Latitude m, Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude – I I I I, Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader ®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 FacilityENFORC--EMENT S ATUS <br /> y A HA LI G ND MANIFES REQ IR NTS <br /> Q Q Q Notice Of Violation 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 /> Q ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IT-1 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q --- --- <br /> 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 I 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 Generatdrs In Compliance No Violations <br /> Q Q . Other: § <br /> Comments �p,,�,�, uses YNILL✓1_ C✓t.Z <br /> wavSwf2��-�trle CTL-v►1 wtd,Cr"L :;�-'P.S <br /> via-Jed h—m 01A&Me sTArea 114 CCS <br /> Inspection Form Included:Q <br /> Comments Included:® -- 7i"l�tG <br /> I Bust,ess R p's Signature. P�ione Number 11; loor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correl> E K I A AA P I:I- -111,2131 ® S <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br />