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Waste Tire Survey & Inspection Report . Inspecti$n��pM N P,; <br /> Y P P <br /> c1WM r181( a Survey Form - Page 1 I Z - 1 0 l 91 1 8 <br /> GwMB 181(Naw nage <br /> Gllfomia Intpntatl Waste Nanagamant eoard - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details - <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: , I Q / ®Routine Q Re4nspecuon Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: ` C fto"n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r " Inspected By inspector <br /> Physical AdBrose / M Q � LJ wkA, <br /> Street Inspection Date <br /> Srorh _G_f- 9s;-Os <br /> Cit - State �Code Time In Time Out <br /> Business Rep Title d O AM O AM <br /> / <br /> J' ar- �e htov t- �- ---�C�C � m•ED O PM m T] O PM <br /> Operational Status TireType 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 /> 1 O fff� O ®Active Q Passenger ®Generator 0 Outdoor <br /> Latitude -��0 Q Closed ®Altered <br /> GPS Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - I I n0 Q End-Use Q Container <br /> i <br /> f Q Planned' Q OTR <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemmenl 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 ®Agriculture Q Shredder Q Other I — <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vt002 <br /> HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> QPRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> QPRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m/ m <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 forNOV orFXT) <br /> Q Q 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 I CIWMB Enforcement <br /> Q i 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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments FaCi I fS exelu.d { <br /> ed rom pQ�mit I w 3 List <br /> �e� <br /> Fa�c;u I s in jnocess or ot4LsPo--Jn all t7rts and will not be <br /> tan <br /> more ee ACLtJor IIs)- k.Pled , 44wt 54t� ►FJft.11Gt dcsck <br /> Inspection Form Included: <br /> Comments Included:Q <br /> Business Re ' Slgnature Phone Number Inspector's SI ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X& (: X A M P LIE1 1112131LIE <br /> 62081 ■ <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br />