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w <br /> �!tate�!aliforniate Tire Su.. ay & Inspection Repors Inspection Report Number l <br /> CIWMB1811st(New Manage) Survey Form - Page 1 11 - 1 0 7 9 3 8 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - ® r Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: sz �/J jy C + — 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> f <br /> Physical Address <br /> / � � �I!3.13®%/ti>�✓+4 <br /> 5,11® A�''74­c Ave- <br /> 74 <br /> vg74 /7 q Inspection Date / 0 <br /> Time In Time Out <br /> Business Rep Title/ t% AM <br /> J O PM O 7 ; [C� ® AM <br /> /✓�1' �j DAN i Y'-Z G��G-�iC2�G f- — — O PM <br /> - - - v - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> f y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � F/ <br /> ® Active ® Passenger ® Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 EXT) 71 <br /> --- <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ------- ---- - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Refe,e. (C- sEnfor,E en <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> e, � .y+ i�r>• ,r��v c Ginty->k 1�1'��- - 11. <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Bu in ss Re -s Si ure Phone Number Inspector's Signature Phone Number_ <br /> INSTRUCTIONS ON I i-x A: P EI 111213 62081 <br /> White Copy: IWP111lowpy:Operator Pink Copy:LEA <br />