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Inspection Report Number <br /> Ile <br /> !!.--=,. Waste Tire Survey & Inspection Report p <br /> r.r CivirM 18i(NewCialif"niSurvey Form - Page 1 16 . 1-0 1 3 6 41 <br /> CNYM8181(New pUe4) <br /> BLUE <br /> c'lif mia hnograbd Waf(e Marug�ment Baartl <br /> Part A-Survey _ Opp pnn�[�n�ppqq K INK EN <br /> Business Profile Inspection Details —��6 J4V dU4hL <br /> TPI - Inspection Type (Fill one) <br /> Site Suffix: / 3 3 Q I3 O ( IS Routine Q Re-inspection Q Referral Q Observation j <br /> Local —_ / If Referral,choose referral type(Fill one) <br /> Identiffer: �L1/r VaL�CG,r/� C C!J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business/ � <br /> or <br /> Facility Name /&)__1V <br /> ) Inspected By Insp tsr <br /> Physical Address j .3 9 =/ , <br /> S'UQao3ivl' � <br /> Street pe <br /> r-IC2 � J Ins ctlon Date D t D <br /> 6ty tate � Time In Time Out <br /> Business Rep Title � 0 AM ) � F/�.y� 0 AM <br /> • � � 0pM r /�1 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all Ihal apply) <br /> Tire Count(Whole/PTE) Q <br /> 0 Active 0 Passenger I*Generator 0 Outdoor <br /> .O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> -_ -• •0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 /> '0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler • Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> yA HAULING AND MANIFEST REQUIREMENTS 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m <br /> Q Q 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> —� (Required for NOV or EXT) <br /> Q Q — <br /> 14 CCR§18459.2.1•Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 114 CCR§16459.3-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 i Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments i kf �j DI7 1 C�a azze:e 46!1 rd" <br /> oto f cd : /'ae.'.G• _ �2� a`—�p r�'�1 � /'2�c�.od< w�� <br /> Inspection Form Included:Qi <br /> 8Z_717,9 <br /> Comments Included: — — - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �-�( <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect:X&rJ EXAMPLE 62081 I Z 3 ® ■ <br /> While Copy CIWMB Yet1ow Copy Operator Pink Copy LEA <br />