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I <br /> ne <br /> Waste Tire Survey & Inspection Report _Inspection Report Number <br /> CgNMerataortea(New 04/01)Callramla Survey Form Page 1 [ I—2 10 7 3 <br /> men3 0 2 <br /> Califomla Integrated Waste Managet 13—d <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f O ! (a n _ Inspection Type (Fill one) <br /> Site Suffix: . ®Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: µp' ��a in C O CHP O CIWMB Q Complaint Q Educational Visit O.Other <br /> Business or Facility Name <br /> Inspected By' Inspector <br /> �Q� h _ <br /> Physical l Ad ass �� 1 [31q] ' � I j co � �C{&f- IID$ 0 , Tk,ryur Rd- <br /> Street (� <br /> 5 01 Y�A —, Inspection Date <br /> City (� "1 State ZIP Code Time In V Time Out <br /> Business Rep Title OAM Q AM <br /> O PM Q PM <br /> OVJAV <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill.all that apply) (Fill all that apply) <br /> s s <br /> Q Active O Passenger .O Generator Q Outdoor <br /> to a Closed O Altered <br /> GPS Latitude i J_1 <br /> ; 0 Hauler Q Indoor <br /> l Q Inactive Q Truck <br /> r I O O End-Use Q Container <br /> Longitude – I I I Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler .O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> 0 O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance"- No Violations <br /> O Other: §,c <br /> Comments J is CL &,n;,,,nnA �p^��n, /4( Ia/SlA �Tf–A �w,o/ <br /> goad i -I D _�. /Jp �S+oy�wl��r�V a v u�. Sect Jot �e^.. /VD,.�r.LI.V <br /> V i o l afie-n s n o fed e Clo�e, rtP t D# V�'' <br /> ed <br /> Inspection Form Included:Q <br /> Comments Included: Number <br /> INSTRUCTIONS <br /> Business Rep's Signature Phone Number n ectol's ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (�V— 62081EX MP I <br /> ■ 07284040031 White Copy:CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br /> — J <br />