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073120S00SS <br /> �- Waste:Tire Survey & Inspection Report .. Inspection Report Number <br /> Sbb of CepfomW Survey Form - Page 1 .I 6 1.0 10 5 9 0 <br /> CNVMa c (N�w OHa1) <br /> Callfornb Inbgnl.d wesb Managertianl 6aard <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� Inspection Type (Fill one) <br /> Site Suffix: r p� ! 9 9 / Q Routine .Q Re-inspection Referral Q Observation. <br /> Local r' n If Referral,choose referral type(Fill one) <br /> Identifier: /lJ Q CHP Q CIWMB ®Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ��� Inspected By Inspector <br /> Physical Address 1 [�R - l 0 f — <br /> Physical <br /> I___t���a s C��- sfi•I <br /> Street <br /> I4eJ Inspection Date <br /> City State ZIP Z!cde Time In Time Out <br /> Business Rep Title O AM O AM <br /> �vt✓ LRVA KAA0 Dy� ,� I IE: O PM O PM <br /> M_ _ <br /> (�� Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) I I 1 �I'1� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> I V ®Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O 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 /> 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS _ <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice rx Violation Q Extension <br /> Q Q <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0. PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompll ce De dBne <br /> 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 /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXTJ <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 Q In Compllance No Violations <br /> Q Q Other: § <br /> Comments _ eo _ •, 1 was received in L /n. Sacmk�-,Jo C' <br /> ,fit LT2 hks_lap V;* _4M.iN ' E EDT maktiAtsf S t a&- bei_ <br /> ( o► cc �t� �i a u-P <br /> ;,rimta_ y►2 . M LTA'_ is d irec4ec( <br /> _Lt Sx w�s,�V- 0 bre_ n s_or ;4, <br /> . <br /> Inspection Form Included:Q ��1 ,,� �� � <br /> 1. ,/1V1�( (X7y <br /> Comments Included:Q �j— <br /> siness e ' n Phone Number In e r s Ig ure. Phone Number <br /> — •— J 62081 <br /> INSTRUCTIONS ON BACK Corr et:� Incorrect: E X A !LA P L E 1 2 3 <br /> ■ - White Copy CIWMB Yellow Copy Operator Pink Copy.LEA .� <br />