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J'3��O�C46$ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWMt181(NCalifornia Survey Form - Page 1 I ._�J -_ 1 0 7 3 3 7 <br /> CgVMB 191(New oaoa) <br /> CalHomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I / j ? Inspection Type (Fill one) <br /> Site Suffix: / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: f a <br /> C.A lei rn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 020– Inspected By Inspector <br /> Physical Address – <br /> 13:1�1_ F/I 9 /-1 L - IG-4 <br /> i <br /> I Inspection Date I a / Q L`I / F <br /> -ep►�Ct �-_ <br /> CitY Sarte %„' Time In �Time Out <br /> Business Rep Title I _1 0 AM ' I m 0 AM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GP$ Q Hauler Q Indoor <br /> O ®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 ®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 I <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 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 /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <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 I 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 1 Q 1 Other: <br /> Comments <br /> -F Wa <br /> _ arl'.e✓ a P •�#` Bati( A41�t✓ vl `two <br /> N e 7b �e-tactil�ct{ —iPtD call 1_ 8 Z_ <br /> (k (o-C& <br /> Inspection FormInclude Q u a <br /> Comments Included:Q 9 V <br /> Business Rep's Signature Phone Number Inspe s SIg a ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X(6� q 1jE�XjAjMj1p LIE[ 1 2 3 62081 <br /> . White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />