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"- Waste Tire Survey & Inspection Report inspection R�dlfft��f�mb��� <br /> us. <br /> l,i SUUof181(New Callf SurveyForm - Page 1 { 7 - 1 01 3 Z 1 <br /> tegrata,Wa(New nage g <br /> Csllfomla InUgrated Waste Management Board <br /> Part A-Survey _ .__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> �,D. Inspection Type (Fill one) <br /> 9 Site Suffix: ®Routine Q Re-inspection 0-Referral Q Observation <br /> Local T y H Referral,choose referral type(Fill one) <br /> Identifier: t 10 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VV Inspected By Inspector <br /> TuF� boy Sa.Ces T 3 - 1 nY �` <br /> Physical Address <br /> SL , B< <br /> 1I ±; Inspeetlon Date } ?J <br /> �_'d�•es <br /> TClil �-f'- qS33D I 1 <br /> city fe Zip Code Time In Time Out T] <br /> Business Rep Title 0 AM 0 AM <br /> ��nn m-m0PM OPM <br /> —3 l Jc2f 5��__ a --- -- <br /> Operational Status Tire Type 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 /> I ' �i I� ®Active j Q Passenger ®Generator ®Outdoor <br /> GPS Latitude 1 ' I I I Q Closed Q Altered ®Hauler ; Q Indoor <br /> __ -- __ _ I O Q Inactive Is Truck <br /> f <br /> Longitude - f i l' I �^ Q Planned Q OTR ®End-Use ®Container <br /> — _ T — <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 •Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <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 <br /> / FP I 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 ERCT) <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 I 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 IS In Compliance - No Violations <br /> Q Q :Other, § ----- <br /> Comments <br /> U, 2DftM We �- - <br /> td mer ' e ' vice r acPP~ts c <br /> V_ e cm—m- l� _CuS_tD _4 <br /> re•��Cc.�- 1-ares �� �� ._� __ uxt�f-�e ��s_. l�-� ._ . . e oro^ <br /> Ilnspection Form Included:01_ \ <br /> Comments Included:(0— — <br /> Business ep's Signature Phone Numberspa ors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:M 0 9 [EVAIMIPILTE11112131 <br /> ■ White Copy.CIWMB fellow Copy.Operator Pink Copy.LEA ® ■ <br />