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Waste <br /> aste Tire Survey SInspection Report rt Inspectlon epo3 �5u0m�b1e3 <br /> r <br /> Slae 8f <br /> CN81 (New ) <br /> California Intgre'edWste Manmien7ent BodSurvey Form - Page 1 - <br /> ILJ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 1 s O0 Routine 0 Re-inspection P 4&Referral 0 Observation <br /> Local If Referral,chse referral type(FIII one) <br /> Identifier: L_�__ ` oo <br /> .,J aQ�� 0U Vt*16 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> —s Yl q'5�S Inspection Date <br /> Crty State ZIP Code Time In Time Out ✓ {p <br /> Business Rep -�, Title J <br /> t__FiY_ ir71&] D O O PM D ! �3 O ®M <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE f (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> { ) t t 5i O 0 Active ®Passenger 0 Generator (a Outdoor <br /> i —, O <br /> , <br /> GPS Latitude I I I IT 0 Closed 0 Altered <br /> -�1 l __ ._ L.__L_ 0 inactive ®Truck Hauler Q Indoor <br /> Longitude - i .! i I I 0 Planned ®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 <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 — ®Other � , $ r1R1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS rT <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> PRC 42951-Waste Tire Hauler R ® Notice Of Violation 0 Extension <br /> 0 0 § Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0. PRC§42956-Registration/Decal in Vehicle <br /> • 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB v <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ---'- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred t CIWMB Enforcement <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 <br /> 101 0 1 Other. § <br /> 0 in Compliance - No Violations <br /> ` r / <br /> commentsISPetDni �h✓�$�lCT �� t1.1Ytf. I��OWIp�Q�y+ <br /> Sia, San i` aOes &n aF w"4;e fees o6 e�r/>,evt f bm CAar4er- u z �ryest( <br /> S ace-esS�v� �hsQe a�w ,s_d_e�i +t tro/af�,�n.sp Pion S "M oc� <br /> :oo awl and Tiymiri At,,s5bU of pica( <br /> Inspection Form Included: ®1 <br /> Comments Included:® yC _ <br /> _ Busin s Reps Signa urs Phon_e r ins or gna ure y phone Nmber <br /> ■ INSTRUCTIONS ON BACK Incorrect:x es E XAIMIPILIEI 111213162081 <br /> White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />