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L`€�S Waste Tire Survey & Inspection Report InspectionRe N K 1rn ru e ■ <br /> rr:. <br /> rr S"4 (New Survey Form - Page 1 1 1 1 4 1 3 1 5 6 <br /> cNVMa i8t(Naw Ouw) fj/ ('1 <br /> calif mia In"grated waste Management Board �7 J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details. I <br /> TPID- S O];� <br /> O Inspection Type (Flit one) --�-- — <br /> Site Suffix: 7 `f .Routine O Re-inspection 0 Referral O Observation <br /> -- - — <br /> Local _ N Referral,choose referral type(Fill one) <br /> Identifier: ,SQL t N O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Buslnne�e''ss or Facility Name Inspected By Inspector <br /> Physical AAdddress �7 �j�� / Z�E <br /> > -�4iQ QO7A,-1-40�q <br /> I 9�6 y • !`"mac 4: <br /> Street Inspection Dete <br /> ity c� ode <br /> ty date 1PTime In Time Out <br /> Business Rep Title OAM Q AM <br /> L` M'�QPM Ell QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) <br /> I (Fill one only) (Fill all that apply) (Fill all that appy) (Fill all that apply) <br /> Active Passenger S Generator 0 Outdoor <br /> GpS Latitude I i i i0 O Closed O Altered <br /> 1 _ ( 0 Hauler O Indoor <br /> --r-- '0 O Inactive O Truck <br /> Lon itude _ � O End-Use O Container <br /> g ' 1 ' 0 Planned O OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer O Collection O Crumb Rubber <br /> IO Service Station O Hauler Agriculture O Shredder 0 Other I Za eNCS <br /> Part B•Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A i HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O p PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data —111:1 m <br /> O O 114 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 O Referred 1 CIWMB Enforcement <br /> O 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 10 Other: § <br /> CC mo�rrrents -� — <br /> �Z T,2 -/0 /uu.Ioee �vQy►�c T�i'�, G'�L'-f - <br /> I li/;r,dcW +z llyleka-40 Sere ZZ �a�,'G- 0n--&& G`ee—.'e# 16Z 179 <br /> I <br /> I wed .pre _ A/CC/L C'V /$4,rf <br /> L�S <br /> Inspection Form Included:O � 2 <br /> Comments Included:® A4, <br /> ! _ Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: o y I RPTA JW P L El 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />