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VOL�2V405:V <br /> cue- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> stet°°t Ca'"°`°`aCNVMB I 1 1088113 <br /> Cattfomla lntegrate4'Waslo Managelm°nt Boar, Survey Form - Page 1 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> site Sumac: / 3 S �J $I O / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: :SgW 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busiinn�essssQo_r Facilittyy Name Inspected By 701 <br /> Inspector <br /> ysicresk iP/LI� ZI1/ F/ L� f �'7A�F/�� <br /> 1 3 ( 32 FA_1Z. _-_✓g_ /�a0 <br /> Sfreet57-0 J/ ��� /✓� Inspection Date D �- It <br /> I '�w�l __L�9' QSZD��—J Time In Time Out <br /> City Siata ZIP Code _ <br /> Business Rep Title (I —II O AM I I O AM <br /> _J_J O PM �I Q PM <br /> Operational Status TireType 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 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude r 0 Hauler 0 Indoor <br /> _ _-__-_. :O 0Inactive Truck <br /> Longitude - ;- 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel 1 <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other S <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUM <br /> IREENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date O / <br /> 70 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required)or NOV or E 11 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Entorcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0- 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments �__ �• � a7']—�—/� 7r�"" <br /> 00f, a p.. A <br /> �1 T� e� � (t�uJ>?��/►VGA` S, 1�a...- <br /> _1t1.9 �— <br /> Inspection Form Included:0 ✓ /( I <br /> Comments Included:0 <br /> Business Rep' nature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK I orrec4 Incorrect: E X a nth P L E -111213162081 <br /> 1 1 2 362081 <br /> White py.CIW Yellow Copy Operator Pink Copy.LFA ® ■ <br />