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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Brare Of Californla Survey Form - Page 1 1 6 - 1 0 0 80 71 <br /> CIWMB 18asteManage Y <br /> Californla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O - ' Inspection Type (Fill one) <br /> Site Suffix: l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `1 ^ If Referral,choose referral type(Fill one) <br /> Identifier: N-�� �ty-1 l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name a.� <br /> Inspected By Inspector <br /> 'P�-�,��J�k <br /> Physical Address \ leo's.IplSQur�oc,�ffi <br /> �.S 2 VJ- �e-�ne,r �Jl.• l <br /> Tt.�Lov,l n� I Inspection Date 6 <br /> s- Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status) Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I,(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ° 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive OT ruck <br /> Longitude - O End-Use O Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q 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 Q Other t,r1e1,,i�, \ex5 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A HAULING ANO MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Pats l I / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requ/red forNOV orEXF) <br /> Q Q 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 0 Rsferied I CIWMS Enforcetbent <br /> Q Q 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 fffen�lltlnae". No. Vlolsttpns <br /> QQ Other: § <br /> Comments <br /> \Lt.C-Zll��f J� v,� jwjern& 2 f A\ � Ar <br /> Inspection Form Included: D 1D� <br /> Comments Included: Q <br /> Business Rep's Signatu a Phone Numb ®Ihsp i Phone Number <br /> INSTRUCTIONS ON BACK Corroat, (fl ff7 r7 ` p7� �! P I 62081 <br /> I 3 � I _ 1. 1 L ® ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />