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0703.80 ■ <br /> Waste Tire Survey 8r, Inspection Report Inspection Report Number <br /> r 1; State of Califamta <br /> CWMB1r1t"-�1 Survey Form - Page 1 I i - 1 0 3 3 0 7 3 <br /> c-11"o <br /> Integraled Waste Managonwrd Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspeetlon Details — <br /> TPID• 1,3L3 <br /> V , ^ - / Inspection Type (Fill one) <br /> SiteSuffix7 Routine' to Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: YlC`L1V1 <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address p - <br /> �ya� CQanl� <br /> ive <br /> 1� — -- <br /> Street <br /> L—� „ / ^,� Inspection Date <br /> A) 61 <br /> City ��1afe pJJfPP Time In Time Out <br /> Business Rep Title,,1,, <br /> S �- M <br /> �O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) nl ,� C) (Fill one only) (Fill all that apply) (Fill Al that apply) (Fill all that apply) <br /> 1 I 1 ll <br /> ®Active ®Passen Passenger <br /> 0 Generator ®Outdoor <br /> GPS Latitude r i I IO Q Closed Q Altered <br /> Q Inactive Q Truck Q Hauler Q Indoor <br /> - - ' <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill ail that apply) <br /> Q Now Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 10 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 t 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> PRC 42951-Waste Tire Hauler R Q Notice Of Violation Q Extension <br /> Q Q § 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 E1 / 01 / M <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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 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 ®In Compliance- No Violations <br /> Q! Q Other § <br /> Comments <br /> — <br /> l,as A'G AUT 'Pa zC'Mr �crV lap- 6Cc <br /> e0l_ Vito <br /> Inspection Form Included:Q �JU• j <br /> Comments Included:® ! <br /> Business Rep's Signature Phona Number inspect Signat a Phone Number_-'; <br /> . INSTRUCTIONS ON BACK I Correct: Incorrect: {� �j X A M P ] 2 3 62081 <br /> Wh-W Copy CfWM8 Yellow Copy.Operator Pink Copy:LEA ® ■ <br />