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0 . 012 <br /> J'"`Waste Tire Survey & Inspection Report InspectionRepo1N fn Lr <br /> State of Form - Page 1 16 - 1 0 1 0 6 8 8 <br /> ctwwa ts>I tNar,oerwl <br /> Calilomia W.pratad Wast.lt.nagemanl 6osrd -- <br /> Part A-Survey-- _— - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID 0 ' j 3 O Inspection Type (Fill one) <br /> site Suffix: 0 Routine Q Reinspection- Q Referral Q Observation <br /> Local -7 ^ If Referral,choose referral type(Fill one) <br /> IdentNier: L / ��-y��-.+�°� / Q CHP Q CIWMB Q Complaint Q Educational Visit Q 011ier <br /> Business or Facility Name \/ /\ ill. Inspected By Inspector <br /> ( _ Pro nf0 's `7Lt r e ZBnL" <br /> Physical Address l 3 Q n( J <br /> aD g E P;►� , - . <br /> Street l/ / <br /> �� Loi (i'l �+� C�u Inspection Date / / F7d <br /> rtG y tate 7 f !Code Time In Time Out <br /> Business Rep Title m;m QQ PM 0 PM <br /> L" L' - Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I �� n (Fill one only) (Fill all that apply) (Fig all that apply) (Fill all that apply) <br /> Active ®Passenger ®Generator &Outdoor <br /> Latitude I I I O Q Closed Q Altered <br /> GPS I I_ I Q Hauler, Q Indoor <br /> f 1 T ,__-1O Q Inactive Q Truck <br /> Longitude - ��� 1;.f I T I I ^j I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer IN Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date M <br /> ,m / m <br /> Q Q j 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 /> jQ 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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ` t <br /> Cil c` usesXowh 71�►'e ens ddtd <br /> ( ,Lr 000u and [,Zzq&& utewed- faf IYD 1) -Fres re cAw_1 <br /> A o ii -&tSq0K _lito O o Wz m ac o lea( <br /> 'Inspection Form Included:Q r �`0' c gyp, <br /> Comments Included:® 6 / _ '?41 '"-�`- q(08-9`6 6 <br /> �*Qsep ignature Phone Number I or gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:?&(I;q IlErXIAMPLE 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />