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f6A � <br /> Waste Tire SU & Ins eCtlon Re O. Inspection.Report-Number <br /> y p p <br /> EfifiG <br /> State of California <br /> CIWMB1811steManage) Survey Form -'Page 1 . C 1 4 1 - Q ,7,: 9 .�1 7 7 <br /> California Integrated Waste Management Board 1� <br /> Part A- Surge BLUE OR BLACK INK PEN <br /> Business Profile. ;�: . . Inspection Details <br /> TPID- ( � Inspection Type .(Fill one) <br /> Site Suffix: (✓' I l <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �N Jo,�r, e;*r« Y. <br /> Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Ins ected B <br /> P Y .Inspector <br /> 1,C..s Do d! e <br /> Physical Address <br /> F V72 `-S e- 02 <br /> Street 12 f a <br /> , / Inspection Date <br /> I aAA)r r� L"A l533,( I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title mm0 AM Q AM <br /> EE 0P m ' m 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE �1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> �+ t <br /> Active -@ Passenger Generator Outdoor <br /> D Q Closed. Q Altered <br /> GPS Latitude m A Q Hauler Q Indoor <br /> p <br /> J- <br /> 0 Inactive Q Truck <br /> Longitude – Q Planned OTR O 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 .Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body. 6) 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 /> —- -- -- <br /> .... <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q .O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O Q PRC§42953.-Contracts with Registered Waste Tire Haulers. •" ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date <br /> m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q . O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other. § <br /> Comments ' --7 ! / <br /> AA JR,-,/ e-, < , f(�c <br /> 'f"K. S:_�Z _Ei'/ /F Wf,7<_,��s^t /✓>in el'-r --,1�-_X42-+5�:�.—lJld:Fl <br /> VA M( l A iN —T <br /> _ {�sto C�— �7'�c( tC' <br /> - -- – <br /> Inspection Form Included Q, -2. r <br /> Comments Included. Q; _ _ ---- _ ' w"`�'t -},�lA• .4Ci. .il�. <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> , l 9 62081 <br /> INSTRUCTIONS ON BACK , Correct: Incorrect: ) w � ,, ,,t y, + -11112 <br /> ■ ' - <br /> White Copy:-CIWMB. •Yellow Copy:Operator Pink Copy:LEA ■ <br />