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0921GQ90506 <br /> ere. <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of Califomla --� <br /> CallforrdahrteFW ISI(Now <br /> we agementeoard Survey Form - Page -1 I 1 - 110 8 4 41 _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I , l O 0 Routine 0 Re—inspection QReferral <br /> 0 Observation <br /> i <br /> Local ��� ' t;^ �� N <br /> If Referral,choose referral type(Fill one) <br /> Identifier: v l/1� ( , Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> A Inspected B <br /> 1 P y Inspector <br /> \GOA, S 1�.. � q r(� <br /> Physical Address 3 ` – l LoLiL&_ �5 !V_� <br /> C ANS . <br /> Street <br /> 104(\ CA <br /> 4(\ CA 'RI Inspection Date <br /> city �- Statc ZIP Cooe Time InTime_Out _ <br /> Business Rep , Title i� , I ��—I Q AM : ;© i Q AM <br /> I PM 1 _1 3 I iPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one onl Y) -. (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ®Active to Passenger Generator Q Outdoor <br /> p O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> IO 0 Inactive Q Trude <br /> Longitude – Q Planned 0 OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 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 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFES REQUIREMENTS <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation !� E•xtension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> O O PRC,§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-om liance - No Violations <br /> Q 10 1 Other: §�____ <br /> Comments m1(� - � — ul+c+d� _ 1. _—--4 — OlJ461 (! <br /> 5- - <br /> 7__Ycvua _eJ1 , <br /> r —- <br /> Inspection Form Included: Q v <br /> Comments Included: Q <br /> Business Re 's r I. Ph ne Number Ins ors Si naturehone Num <br /> 9 ber <br /> INSTRUCTIONS ON BACK IC-IXIAIMIPILIEI 1112E 62081 <br /> White Copy. WM Yellow Copy.Operator i, Pink Copy.LEA <br />