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073S4040062 <br /> Waste Tire Survey $ Inspection Report Inspection Report Number <br /> 111 etalaOrC11"I lla Survey Form - Page 1 1 5 - 1 0 7 3 4 9 4 <br /> CNYMe 1111 INaw 04re1) - <br /> Ca1NOrtda Integaled Wafter Management Board —- <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- _ ( Inspection Type (Fill one) <br /> Site Suffix: � 7- - 0 Routine 48 Re-inspectionection oReferral 0Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L Sir. _ m Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addres <br /> _1.10__.5• SF . I <br /> SLvef � <br /> Inspection Date L Z <br /> �•y �� � �t 1 <br /> TimeIn__ _ _ _ Time Put <br /> Business Rep Title I I )O AM O AM <br /> PM <br /> 0 PM <br /> - Operational Status Tire Type 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 /> r 1 ®Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS 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 ( 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§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 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 for NOV or EXf) <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 f CIWMB Enforcement <br /> Q 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 I*In compliance-- No Violations <br /> Q 1 Q 1 Other: § <br /> Comments 1 <br /> - -1✓15 'y"` Ol'` ��s c�let �� sttyZIA no, <br /> C /V1 } <br /> Tl1 S � v <br /> `c-S 2t11s` /a CO �d—�s;hares A.�,-aLar�i_?��; . <br /> !Inspection Form Included:Q <br /> Comments Included: <br /> i O Business Rep's S �ature Phone Number inspector's Signature - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect:X(1) q E IX I a llil. P I L I E 1 1112131 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />