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WP: e Tire SuOy & Inspection Report nspection Report Number <br /> LLs, 5 ate o California ' <br /> California Integratd1Was eeManagement Board S u rvey Form - Page 1 10 <br /> At f 3 1{�2 5 )7 <br /> i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ss Profile <br /> Inspection Details <br /> —_ - - <br /> Inspection Type <br /> eQ(Fill one)TPID- <br /> Site Suffix: Routine Re-inspection Q Referral <br /> Observation <br /> f - - <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: "tr'N I`,T, <br /> 1�,.(�'t l�•�.t��,.�i•� �Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address j / - <br /> Street <br /> Inspection Date <br /> City State ZIP Code <br /> � M1 � Time In Time Out. <br /> Business Rep Title O AM _ AM <br /> � ._ : [T <br /> O PM ��' O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> y Q Active Q Passenger Q Generator Q Outdoor <br /> Elm <br /> O Q Closed Q Altered <br /> GPS LatitudeLj] E ,f .I Q Hauler Q Indoor <br /> Li O Q Inactive Q'Truck <br /> II <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> IIII - <br /> rts , . pe (FIII all that app(v) <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> I ' <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q I Q PRQ Notice Of Violation Q Extension <br /> C§ -42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§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 Date m 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 EXT) <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/CIWMB Enforcement <br /> Q Q 1 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> l l ty'•'rCi(�;:1 r � ;.i 14 k.'A`.P �N i0� i ;�� S.r -- - <br /> Inspection Form Included: Q, <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />