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�g? 59�4:g5� 4 <br /> Waste -Tire SuOey & inspection Repon Inspection Report Number <br /> StaCI MB 81of 1(N w04,04) Survey/ Form - Page 1 I 1 - 1141175 <br /> California Integrated Waste Management Board J g <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- FIT�j <br /> OInspection Type (Fill one) <br /> Site Suffix: ` D [C] Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local ,\ If Referral,choose referral type(Fill one) . <br /> Identifier: S(�� U _ n _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I <br /> �i�10.-s0 r3 1 n <br /> Physical A ess I T I <br /> 11 <br /> 13a5 s_ Cvm.f.tvr_c�--5 .— I - - <br /> Street <br /> Inspection Date <br /> — C _ _ <br /> City State ZIP CoueTime In Time Out <br /> Business Rep ' Title 0 AM 0 AM <br /> PM I I ' I I PM <br /> OperationahStatus Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' ' l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator <br /> � 9 ® 0 Outdoor <br /> Closed, Q Altered <br /> GPS Latitude I I I . I I } 0 Hauler Q Indoor <br /> 0 Q inactive Q Truck <br /> Longitude I . I Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair . Q Trucking Fleet Q Government Q Retreader Q Dismantler- Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection. Q Crumb Rubber <br /> LQ Service Station Q Hauler Q Agriculture Q Shredder Q Other i I <br /> Part -_Inspections of.Waste Tire Dealer,Generator, Hauler and End-Use Facility ;,'16 <br /> ,..,a>.. S-..�. � � �. <sa :, ,f�' rostarz <br /> V�� A 'HAULING AND MANIFESTREQUIREMENTS Q Notice Of Violation �Q <br /> sExtensron <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> § Registered Waste Tire Haulers. <br /> 0 0 PRC 9 42953-Contracts with Re <br /> Compllance,,,Deaiiline <br /> 0 O <br /> PRC§42956-Regis trationlDecal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMBb <br /> 'b" `(RerEX7Jy <br /> Q 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days quired..forN <br /> E � a $% OV ' <br /> Yn �i4' 5 <br /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years �� <br /> Q 0•• 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire.Haulers QReferred!CIWMBEnforcement;� <br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities , e <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators " r <br /> ®uin'Compliances No Violations <br /> 3 <br /> 0 0 Other: <br /> Comments ,Vik( n5 ` C ~7 s og- <br /> r <br /> Inspection Form Includ /� <br /> Comments Included: •VVVf`/ �(��� - _- _ _�Qqg-3g_ <br /> usinesS Rep's i ure Phone Number nsp or's Signature hone Number <br /> INSTRUCTIONS ON BACK Corect �:Inco�rect ( a E1XIhll P. E�111213 <br /> 62081 <br /> White Cop CIWM Yellow Copy:Operator Pink Copy:LEA <br />