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i <br /> ccz ' ' <br /> H Statof California Inspection Report NumberWaste Tire S*ey & Inspection Re„oom <br /> Ce181(New <br /> California.lntegrated Waste Management Board Survey Form - Page 1 1141271 <br /> ■ i <br /> _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 I a 9151{ F6 I I 1E) <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: //,' <br /> "l n u{tJ Q CHP Q CIWM B Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected BY Inspector <br /> V) -�” P <br /> ( <br /> Physical Address t L-1-1 0 ( ' (S <br /> �.� <br /> Stre� <br /> Inspection Date <br /> City State Zlp Code Time In L\ Time Out <br /> Business Rep Title '.....–.-..-_.__.._. <br /> 0 AM i Q AM <br /> PM ! � ' � OPM <br /> l – --- <br /> �_.__.___ a L_____ Operational Status TireType__p ype Business Role Storage Type <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t f I ` 11C) f <br /> t0 Active Q Passenger (P Generator (t) Outdoor <br /> i D Q Closed Q Altered I <br /> GPS Latitude _ –� Q Hauler Q Indoor <br /> Q Inactive ! 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 0 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 Q Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A7 HAULING AND MANIFEST REQUIREMENTS m - ! v <br /> Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years --� <br /> Q Q . 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB .Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations _ <br /> Q Q Other: § , <br /> Comments !k <br /> -1 Cr Q�� L i n r�' nJcd . <br /> Inspection Form Included: Q, t <br /> Comments included: Q, �. '( ` <br /> Bustness eps lE,ignature Phone Number _ Inspectebr's Signature ` Phone Number <br /> INSTRUCTIONS ON BACK !Co a Incorrect: X V � X A'MI P 3 62081 <br /> ■ White Copy: IW Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br /> i, <br />