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Waste Tire- Survey & Inspection Report. • .Inspection Report Number <br /> State crWM 181(Now Survey,Form - Page 1 1 1 - 10 7 3 5 4 9 <br /> CIWMB t81(New Oa104)� <br /> califomia Integrated Weete Management Board <br /> Part A-Survey BLUE OR BLACK.INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 1 -41l ! 0 Inspection Type (Fill one) <br /> Sitesuffix: I 3 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier _yy0.ga. ,,. _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J U Inspected By Inspector <br /> Physicsddre_ss <br /> I ego 2-O N . �y,c-At�Lr_F�>z.✓�r_. I <br /> Street <br /> Inspection Date <br /> City GA State� 'Z-P}d Time In Time Out <br /> Business Rep cC Title 0 Am 0 AM <br /> m'm O PM EEI:EE] OPM <br /> t_�f_i.r.1M G_Rt/.i�n___✓f_.J t.O _ct:�-tD'r.C__ -_ Operational Status•Tire Type '. Business Role: Storage Type <br /> r II <br /> Tire Count(Whole/PTE) ' Fill one only)I 1.(��yr ( Y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f• I ( ° F 7 ®Active .Q Passenger 0,Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ` <br /> O Q Hauler Q Indoor <br /> r� (— Q Inactive Q Truck <br /> Longitude T 1 Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J� -- - - <br /> Q New Tire Dealer Q.Auto Repair Q Trucking Fleet Q Government p Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q.Hauler Q Agriculture. Q Shredder •Other t_ �att4Uvt a� 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extensio <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 <br /> Q O 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittahof Comprehensive Trip Logs within 90 days (Required for NOV or F,CT) <br /> 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 I CIW MB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q 10 Other. § <br /> Comments <br /> dLiil. : ,c elyL fit ¢rLol ttl - <br /> _. Rol{ -C CA, N e <br /> Sn„o,ce c_�Guvrsl t t�ori_ru�.•� No vy -1 w*%tLe&T ------- <br /> 1 <br /> Inspection Form Included:Q x <br /> Z <br /> Comments Included:Q <br /> �(,4—06 3 <br /> Business Rep's.Signature Phone tuber �spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK. •rte•t Incorrect: E x A M P .L E i 111213 62081 <br /> ■ White Copy.CIWMB' Yellow Copy:Operator Pink Copy:LEA ® ■ <br />