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Waste Tire Survey & Inspection Report 'Inspection R��1�Fi'RW� <br /> StateoTCalHomla p p — - --- � <br /> -�R CIWMB181 thew gUe{) Survey Form - Page 1 ; 1 6 - 10 1 3 2 4 5 <br /> calif mia Integrated Waste Manag*m ,8—rd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> site - ( -7 z / S _ Inspection Type(Elle one) <br /> Site Suffix: l l ®Routine Q Re-inspection Q.Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: , � �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BuOTIK.040i_ <br /> nititifieress or facility Name Inspected By Inspector <br /> Ph <br /> LS3r <br /> Street <br /> vF'�a�_ G G1s�5'I Inspection Date <br /> 4ty State fIP Code Time In Time Out <br /> Business Rep Title Q AM O AM <br /> J �—^ Q PM Q PM <br /> t.w"� 7�� a� NI , <br /> _ - = I Operational Status Tire Type .Business Role Storage 7�� Type <br /> Tire Count(WholelPTE) r ( I / r � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r , Active ®Passenger ®Generator ®Outdoor <br /> GPS LatitudeT 1 IO Q Closed Q Altered Q Q <br /> J II Hauler Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V I A I HAULING AND MANIFEST REQUIREMENTS ®Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements Date (�{,® / FcH <br /> Q Q 14 CCR§18459.1(a)(b)(c)•Tire Program ID Number from CIWMBI`-I 11 �'1� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E)M <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers (D Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments Q+� 't r QL��.,I✓,ti�2i CJ 1— ,ly J C. i r'4 <br /> —I V�Y`�Gr ►"".! '�'� V"r""� Ste'a�LCa.!—!_�Y'�✓._..—N'�.1�✓►.P�✓"w <br /> Inapectlon Form Included:® <br /> Comments Included:® Wos <br /> ep's Signature Phone Number I _re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON 8 Cormct:0 Incorrect: JEJ rAIMIPILIE1 1112131 <br /> . White Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />