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08066040058 <br /> "" Waste Tire Survey & Inspection Report. InsPection Report Numbers-te of � <br /> C1WMl31li( w SurveyForm Page 1 1 2 - 1 0 7 3 4 0 1 <br /> CNVMB 1e1(New tluwl <br /> califomia Integrated waata Management Board. <br /> Part A-Survey BLUE OR BLACK INK PEN' <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ffi <br /> Site Sux: F 97 QE] ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: ,' Da Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address [ail [dJil ,V`GI/(,41ti 4-a�,e j <br /> Street / ' / O <br /> Sia h�/�! Inspection Date <br /> City tate Zipode l Time In Time Out <br /> Business Rep + Title 0 AM 0 AM <br /> 'm O M m'm 0 PM ,. <br /> Operational Status Tars Type _. Business Role Storage Type <br /> n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Cobrit(Whole/PTE)' <br /> ®Active ®Passenger ®Generator:. ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container . <br /> Business Type (Fill all that apply) LL _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®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 f <br /> Part B-Inspection of Waste Tire Dealer,.Generator,Hauler and End-Use Facility ENFORCEMENT SM&Tjis <br /> V A HAUL PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> N AND MA IFES REQ IREME S Extensio <br /> ion <br /> O O Q Notice of ViolatQ n <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Ueadfine <br /> O O PRC§42956,Registration/Decal in Vehicle <br /> O O <br /> 714 CCR§18459 =Responsible Entities Complying with Manifesting Requirements <br /> O . Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FX7J <br /> j0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O i Q 14 CCR§18460.2-Manifest System Requirements.for Registered Waste Tire Haulers Referred!CIWMB Enforcement <br /> 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 ®In Compliance - No Violations <br /> O O 1 Other: § U <br /> Comments ( BYE `I{rU s ,•j n�-,e - �� E/I�QS y10 ftQ <br /> Rre P r e <br /> k� posrj u kf onatPeA w_ar�, Tint Gul,� aLw I7 r ih u'- ar- <br /> wt - -P.(SLS V_ieWtd . IJP✓i oI -s no-f_ec� <br /> Inspection Form Included:QZee <br /> '(&6 <br /> Comments Included:Q !�(0 <br /> Business Rep's.Signature Phone Number Inspectors Sigr ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �o reef: Incorrect: E XAM P L E 1 2 3 <br /> - ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® '. <br />