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r— <br /> 0l v IS J0 1• ;i <br /> �1= Waste Tire Survey-& Inspection Report Inspection Report Number <br /> 111 State of California ■ ' <br /> CFWMB astoMoage Survey Form - Paye 1 1 9 - 1 0 7 3 3 4 1 . <br /> California Integrated Waste Management board <br /> Part A-Survev BLUE OR BLACK INK.PEN <br /> Business Profile Inspection Details <br /> Site - ^ _ O Inspection Type (Fill one) <br /> Site Suffix: .L *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JDr _ _ Q CHP Q CIWMB Q Complaint .Q Educational Visit 0 Other <br /> Business or <br /> � 7E_,-_� _ <br /> Name �, s 1Ins3pected By Inspector <br /> I � <br /> Physical Address LT <br /> - a- <br /> �� <br /> I 10001>1 <br /> Street i / / o t <br /> /•} �J C+ 15d� ( Inspection Date <br /> city Srafe ZIP Coe Time In Time Out <br /> Business Rep Title OAM O AM <br /> t 1f• I�6art [L] 0 PM m m 0 P <br /> —] <br /> .Operational Status.-Tire Type Business Role. Storage Type .' I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> Tire Count(Whole/PTE) 1 1 Ir 0 <br /> _ .�' _ . _ ;1 �___ L__I ®Active Q Passenger. .0 Generator _ ®Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude �, Q Hauler Q Indoor <br /> 0 O Inactive ®Truck <br /> Longitude �. Q Planned Q OTR O End-Use Q Container <br /> Business Type-(Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body .Q Car Dealer Q Collection . Q Crumb Rubber ::Lt <br /> M__In <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 . ENFORCEMENT-STATUS_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O p Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decalin Vehicle <br /> O O 14 CCR§18459.-Responsible Entities Complying with Manifesting Requirements pate T / T / T <br /> p O 14 CCR§18459.1 Tire Program ID Number from CIWMB <br /> Q O 14 CCR§'18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers• Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-UseFacilities <br /> R§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 00 O her, § <br /> Comments �?Mdfm z• Aafe I . •• c e S Q��_kc <br /> asf erg ride. 2 _-- 3 • SJ : TLe };rftit s <br /> v��vt►ed e�l�e� 13ow�rc�c¢ors on �i#� �naH..a�., fz�'c5 a �-I! rV►A.h.C.�cS+ <br /> Inspection Form Included: 0 <br /> Comments Included:40 1s–.Rep's Signature Phone NumberInspeSignature.. Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect:X(6-Pd •E x W ( 2 3 P E fl 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA . ® ■ <br />