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s7i3i9i74�i5d <br /> cre- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> cralawm'R'11(N.la Survey Form - Page 1 1 1 - 1 0 7 3 4 7:41 <br /> crvvNe tat(New oaaal r,/ <br /> LalHornla Intagratad WaaH Na nagamanl Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 / O Inspection Type (Fill one) <br /> Site Suffix: Il I-13 Fz 1 1@ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Kq ,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name q Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> cA <br /> StS t bode Time In Time Out T <br /> Business Rep 1,,I Title &AM0 AM <br /> 1� ._�1 Idx�COw1���I �f m mOPM m m OPM <br /> �_ -- — <br /> Operational Status Tire.Type. Business Role Storage Type <br /> I ! (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE): ,.I E I r .Z 9 1 <br /> I.. I I_. l e Active S Passenger 0 Generator 0 Outdoor <br /> W. O i Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 !Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF�ORC-EMENT STATUS <br /> RM11HAU1LING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Eutension <br /> Q Q <br /> PRC§42951-Waste Tire.Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 for NOV or EXlJ <br /> • Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 010 Other: § <br /> Comments ` <br /> 15pCt Q t1T 1 —Qy�4u, <br /> r10 ��/G.ir_i'--Cwc<<l._--�ux�—,�.[�.1.�.�f�._Kc�tw_.�.—►zr� t��.y-�,•rsa. <br /> 19( <br /> r <br /> ObSc,nc_- �Cct //-'1�- /}/�o/ �z.urn_� �/tr_n►.n. _v�ca,�hr _/_ss-acs <br /> Inspection Form Included:Q (. ��0(o Lj <br /> Comments Included:Q <br /> Busindss Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X R M P L E l Z 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LFI+ <br />