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D91�205Qt)! 7 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ri CfWM fCaifoel Survey Form - Page 1Ff�l - 110843 3 <br /> gWMB 181(New nage y ('� <br /> California Integrated Waste Management Board `� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• Inspection Type (Fill one) <br /> Site Suffix: � � 3 t ` C 1 13� - C��J 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _I , n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _6UA I I <br /> BuQ* e;ss or Facility Name Inspected B <br /> P Y Inspector <br /> cnaiz\ - C4c_ .5 S �:e,� �C <br /> Physical Address --� iW� � <br /> 1 <br /> .Pas�, d� ----- � - 1 <br /> o <br /> Street L( 1 L� <br /> 1!5 Inspection Date <br /> city 4.0 <br /> Siad -LIP Code Time In <br /> Business Re Time Out _ <br /> �� r <br /> P Title <br /> O AM I j� Q AM <br /> i�4JV - -- - .0' r `C/�✓ MM..'' I l� —� • I S PM �- - I - -I- --I • PM <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 /> r ° •Active Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � ; � � Q Hauler Q Indoor <br /> ___-O Q Inactive 41 Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) torhj&t <br /> Q New Tire Dealer Q Auto Repair Ci-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 Q Hauler Q Agriculture Q Shredder ® Other S� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM -N STATUS <br /> V =1HAULI G AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. -ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs Within 90 days (Required for NOV or E)C7) <br /> Q 41 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/GIWMB 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 a In C-ompliance No Violations <br /> Q Q 1 Other: <br /> Comments Q _x4 A Jjan o flaw , <br /> nek QNCAII'me _ <br /> t <br /> Inspection Form :ncluded: '7 <br /> ncluded: Q s n J /1 \{1 '1� nye t•�� <br /> Comments t . Lg- <br /> Business Vep'sdSignature Phone Number ns' _ or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre In rrect: ��jEjXjAjMjP1LjEj1 '.2 3 <br /> ■ White Copy. WMB Yellow Copy.Operator Pink Copy LEA <br />