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® = Waste Tire Survey & Inspection Report Inspection Report Number <br /> lG�t State of CaliforniaCIWi/''�f �/�i +r+�. /' <br /> California lne grat d'Wase81 eManagementBoard Survey Form - Page 1 �,f L/ �,/ + 4 <br /> Part A- Survey__ ---BLU E OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 4 Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 15 '>��A , -_�� 1.v, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V - - -- -- -- - - - - <br /> Inspected By Inspector <br /> \r M tZb� <br /> Physical Adckess 3 <br /> Inspection Date 3 5- <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> 57 0 PM <br /> �.C.i <br /> O PM 1�► <br /> C\T Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 1 ®Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body # Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shre�der 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport c`Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ! Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CI NMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or Ek <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ;f s <br /> x• <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers0 Referred[Cl Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ® <br /> In 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators t e - <br /> ® Co nplianc No Violations <br /> 0 0 Other: § C - -- I <br /> - ------- <br /> Comments --� I 1 I <br /> ihS�-[-�'C <br /> T <br /> o <br /> Inspection Form Included: 0 q <br /> Comments Included: 0 <br /> Busis A % / <br /> Rep's Signatuw Phone Number In ector's Sign re Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect X (�,+ I A!MI F 2 2 3 62081 <br /> ® White Copy:CIWMB Yellow Cc_.-Operator Pink Copy.LEA <br />