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® .= Waste Tire Survey & Inspection Report ���Inspection Report Number ■ <br /> r�r atete W 181(Now <br /> ' r . ,i O �j /� C <br /> envtdW tteweuw) Survey Form - Page 1 I ' 'Vl Ir 3y U <br /> Caafomle totep rated Weeb Manepemerrt Board <br /> 21 <br /> Part A-Survey _ _ BLUE Q$BLACK INK PEN <br /> Business Profile _ -- Inspection DetailsUVVttVV 7A o lg <br /> TPID• - Q 1 i Inspection Type (Fill one) t UV <br /> Site Suffix: 1 151 qT�� f ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��— - ([ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business oorr Facility Name V/j Inspected By Inspector <br /> Physical Addrghs <br /> I ]3b—/ <br /> Dip t�► C ! — <br /> Street / I001 <br /> � C49533Co Inspection Date , arol / <br /> ,ry .—` - Srare�ode <br /> Time In Time Out <br /> Business Rep Co Title �A m O AM m O AM <br /> L 1 _W C7^- -- —' —� J"1 �J O PM '-`- -- - -O 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 /> t ®Active Q Passenger ®Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor' <br /> Q Inactive ®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 ®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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V : A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q j 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 Date <br /> 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 EX7) <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 i CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 014 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS in Compliance • No Violations <br /> Q Q Other. § <br /> Comments V W DIY �t%f��1 I' (`l t P• leo Vj� uJa Wilson Wa y <br /> aLi des of `ftp- nF_ �,-4_rvi11 iyvcic_s 0c jwk <br /> � —_ C�1✓ _cYa f�/� nFFr M n avy a n ,_ G_ I q _CCe_.._l S vt f a -- <br /> Inspection Form Included:Q 'F' ✓, �0�� �� <br /> Comments Included:•I � <br /> Business Rep's Signature Phone Number n or• gnaf24r`. Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 incorrect:X i& IEIXIAIMIPILIEI 111213162081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />