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07312040457 <br /> =ur. <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> S�`a°r`al(New Survey Form - Page 1 1 6 - 1 0 7 3 5 1 2 <br /> cnvrne tet(New y ry <br /> California Integrated Well,management Board 7 J <br /> Part A-Survey _ BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection M/ 3 <br /> SO3Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: �nrt I o"��a.n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - -- - -_-- <br /> Inspected By Inspector <br /> cc(f �x <br /> Physical Address ---) LA <br /> 1 8 3 5- /�cr�, �H r{ l�r <br /> Street <br /> Inspection Date <br /> I S+vc k i GA 95zbL <br /> City —date Time In Time Out <br /> Business Rep Title m m PC PM m m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 1 I l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> , t' I � !, I <br /> S Active Q Passenger ®Generator Q Outdoor <br /> GPS I I It <br /> I — �0 Q Closed Q Altered <br /> o Q <br /> Latitude Il L Hauler Indoor <br /> _I Q Inactive ®Truck <br /> Longitude — t=. I Q Planned Q OTR Q End-Use Q Container <br /> l I L------���,LLL ���LLL— <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFO C-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violatio Q Extensio <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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOVor <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 Generators In @ompliance - No Violations <br /> Q 1 O_j Other: § <br /> Comments <br /> /tazc%rn.�c %r1-C�Jcc�'iLr-��ycr -� <br /> _Cs—�r..v� --T_�rt--rzfr •�i�__ Naues-.�U#r_100SS_�'`� V�I__ TLS-t4�•ur-ecl— <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> ��LL/ t 7 eze-))r{6F-662 Z� <br /> Busines s_ ignatu hone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �orrec• � Incorre•t: E X A riA P L E 111213 62081 <br /> ■ W hila C py CIW Yellow Copy:Operator Pink Copy LEA ® ■ <br />