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oa2��o400i� <br /> jaWaste Tire Survey & Inspection Report InspectionReport Number ■Stateof S181(cr°� Survey Form - Page 1 �I1 - 1088215 <br /> CIN.tod W (New nage Y <br /> California Integrated Waste Management Board ,— —.--.- <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> identifier: _�q,J �pp\Q_ a � ,y� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _ e <br /> ' T, r _ ' � _i0it <br /> Physical Address <br /> 2 5- --- -C-72AN 1_c.�V%ie--2.8 _ <br /> Inspection Date <br /> eA"---- CA <br /> ---- `-J 3. bi Time In --' Time Out - -- <br /> Business Rep Title ! O AM 0 AM <br /> O PM 0 PM <br /> HA �A,���.o. ow,.�e tZ - - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r S <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use le Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 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 Date m / m / m <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 E0) <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/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 •In Compliance - No Violations <br /> 0 0 Other: <br /> Comments N s� �a^ 4riq/. Gf Ate(>G f /Ate.✓ L./Q-4 /1 <br /> �No_�: !� � ,Q,�'� NA��/�-�l�J�r 'l/i 0.s /�-+s(//�6�'L?u7�=•�/q✓�i i���.A/ <br /> 'rte -Q.�.-Q.�a!//� i4.✓/ S v_f'utl Iz D. Na r/"a_/_p rv►�f S o�C/ �` — <br /> Inspection Form Included: <br /> 0 0 <br /> 7 46896 <br /> Comments Included: <br /> �Bykindrss Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK C rect. Incorrect:�(� E X A IM P L E 62081 <br /> 1 2 3 <br /> ■ White Cop.CIW Yellow Copy Operator Pink Copy:LFA ® ■ <br />