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Waste Tire Survey & Inspection Report inspection Report Number . <br /> CIW B 18 (New <br /> I 1 - 1088152 <br /> CWMB781(NewM/04) Survey Form - Page 1 <br /> calilornia Integrated Waste Management eoartl <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �//�� ��, Inspection Type (Fill one) <br /> Site Suffix: I I I - I - / •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. �VN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> i d�i a.w1 S 7A-,jjkCil _ , © <br /> Physical Address <br /> i Iq-�_ <br /> Street <br /> Inspection Date <br /> —�clZ�la-s-t �4 95Zo(o J <br /> City Stage Time In Time Out <br /> Business Rep Title I O AM Q AM <br /> — -- `--— <br /> OP '= O PM <br /> -- - -— - -- L— - --- -- <br /> . Operational Status TireType Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one.only) -(Fill all that appy) (Fill all that apply) (Fill all that apply). <br /> 0 Active 0 Passenger do Generator 0 Outdoor <br /> -- _I - - - 0 0 Closed Altered <br /> GPS Latitude I 1 J I-- I -Jl 0 Hauler 0 Indoor <br /> LL <br /> _ - -'-- ---- 0 Inactive •Truck <br /> - -- -=T O <br /> Longitude -. I I' ' II O 0 0 End-Use 0 Container <br /> 1 I.I Planned OTR <br /> Business Type (Fill all that apply) I <br /> 0 New Tire Dealer 0 Auto Repair [�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 0 Other 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 O <br /> PRC§42951-Waste Tire Hauler 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 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 for NOV or EXT) <br /> 0 O _ ------ - - <br /> 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 Rof /CIII WMBRE-forcem <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 ®In C-ompliance - No Violations <br /> 0 10 101her. § <br /> Comments �/�.r✓� �Ns���t"� es-r �_��_,_'Z.t.. /},e'�a✓�'�L•tWLt.6t�9_•T�.. <br /> —��twP�4t �_ ..._M�._- �G�y3 �3�7�—Y�.t'fq_��-�-/(r� �•iG �t.wp.4^� .-/Y1�tt��(s <br /> —�/-lu/�-�- -�D-�/-f���lar-rs/ —Q_7_s!i�-Ciw s+s✓�/611<.�P'• !/ � - <br /> Inspection Form Included:0 til O9q <br /> Comments Included:0 r �t�- `o' <br /> Business Rep's Signature Phone Number Inspector's S°gnature Phone'Number <br /> INSTRUCTIONS ON BACK Correct• Incorrect: jEjX-JAjMjPjLfEj 1112131 62081 <br /> ■ WhiteCtyCIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />