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982270401.34 <br /> €,. Waste.Tire Survey & Irnspection Report I"spection ReportNumber ■ <br /> s�"orce�I(Ne 04/ Survey Form Pagel -1 3 - 1. 0 10. 8 7 5 <br /> CIWMe 181(New <br /> CalNomla Integrated Waete M..........oard _ <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- I , _ © / Inspection Type (Fill one) <br /> Site Suffix: 11 1 5i 11 II 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: SAS O." _�j <br /> „ C 0 •O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By <br /> Inspector <br /> Physical Address <br /> 10040 5. HA4L&Q <br /> Street / n 0 / O a <br /> /1 q 5231 Inspection Date L m <br /> City State Zip Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> e- ./Ct �4&tC�QC.r • �O PM m'm O PM <br /> n j Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelP7E) i I !� $ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> lActive O Passenger i Generator •Outdoor <br /> GPS Latitude m I I I I Iv O Closed O Altered OO <br /> Hauler Indoor <br /> O Inactive 0 Truck <br /> v <br /> Longitude - I I I I I I O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair IS Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection . O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B-Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facilityr..V aA1gg BENT SLT STtALT1US <br /> 110VAIIIII&A01111111IM111.111MGMND MANIFEST REQUIREMENTS <br /> O OO Notice Of Violation O Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> i <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 <br /> OO 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXTJ <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§.18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> O O Other: §_ <br /> Comments N fr- <br /> J s�v»> re,�,_a►�' -dam ti `— - WF_ <br /> _iz,:��...-�.v�_t�td.,0-=9�GY.f..-�y—�,�•O.c.<,,Gl S .EO_- ,�.,..;_/'.GA •'S <br /> _�rc— �aV!_2fT�w.��,.df!/ S—✓�'Q•u/_�_ �a ✓i'F��..�-1 b-.� s qi�-�✓ �..� ' <br /> Inspection Form Included:O <br /> Comments Included: ` ��� <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co a.. . Incorrect: I E-IXI AIMI P[L 1 E[ 1 1 11,2131 62081 <br /> ■ - While Co .CIW 7 Yellow Copy Operator Pink Copy.LFI\ ■ <br />