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— -- ----- -- <br /> 0�2620'60010 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> • awnta 161(New 0"Al) �raos, Survey Form - Page 1 I $ - 1 0105661 <br /> CAllfornle rrtleeralee weau kU-n ems BLUE OR BLACK INK PEN <br /> Part A=Survey <br /> Inspection <br /> Buslness Profile Details <br /> FTPID I/^� p' Inspection Type(Fill one) <br /> fix: r 4 9 3 lL/ O O *Routine Q Re <br /> -mspection Q Referral Q Observation <br /> Local - -- - — If Referral,choose referral type one) — <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business oAac'� meInspected By Inspector <br /> Physical Address � - <br /> lung <br /> Street r Inspection Date <br /> �I'�33� 1 UU <br /> rty State IP ade Time In Time Out <br /> 0 AM <br /> 0 Am <br /> Business Rep Trite - r,' m- PM 1= PM <br /> — ---- --- Operational Status Tire Type <br /> Business Role Storage Type <br /> (Fill one on (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> Tire Count(Whole/PTE) r , <br /> ®Active Q Passenger I Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - — i Q Hauler Q Indoor <br /> _D Q Inactive ! ®Truck <br /> '( r <br /> Longitude - j Q Planned ®OTRQ End-Use Q Co <br /> , � FAF' <br /> Buslness Type (Fill all that apply) I II <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fue <br /> Q <br /> Deafer Collection Q Crumb Rubber <br /> Q Used Tire Dealer Q Auto Body Q Car <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other �( 1 rdM L�l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS —_- <br /> V A 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXr) <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - <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 014 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 ®In Compliance - No Violations <br /> Q Q Other. §IF—comments - <br /> A I - �� 7Y1r1 'C• S TQ �'}7A 1 S - .Sl�fY1 _CJS <br /> _ Mf <br /> - ( A , ! <br /> f as(_J s Win. 0-1 2y©o �L Aue,tip• <br /> -trayl�`1llis ac Gess iS <br /> r'kirfLfor-- <br /> _ h / Oct <br /> Inspection Form Included: T I � tL ! <br /> K<(/�Comments Included: - - "7 usiness net re Phone Number I toPhone Number <br /> l - — -- - - 62081 <br /> INSTRUCTIONS ON BACK Correct: ncorrect:x(&9 E X A1 2 3 ■ <br /> ■ While Copy.CIWMB yellow Copy.Operator Pink Copy:LEA <br />