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07312046442 <br /> err_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClwMfC1(Neal la Survey Form - Page 1 ( 1 - 1 0 7 3 31 8 <br /> CIWMB 1E1 blew nage <br /> California404) <br /> Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID - O I Inspection Type (Fill one) <br /> Site Suffix: Fil 31 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Ref <br /> ``a� Q erral,choose referral type(Fill one) <br /> Identifier:' CHP Q CIWMB Q Complaint. Q Educational Visit Q Other . <br /> Business or Facility Name V�VInspected By Inspector <br /> �-(Jd ib fi�rep�u I _ <br /> Physical Address <br /> �J 3 Mot <br /> A/C - <br /> Street �ry <br /> �J Inspection Date <br /> I D —J Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title 0 AM 0 AM <br /> 'm O PM m m 0 PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> If I )O '(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WhOIeIPTE) <br /> vl. ®Active ®Passenger ®Generator ®Outdoor. <br /> OO O Closed Q Altered Q Hauler ®IndoorLatitudeGPS �I� Q inactive Q Truck <br /> Longitude Q Planned Q OTR O End-Use Q Container <br /> FT-1 <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®.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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFQRCEMEN1T STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> O Q Notice Of Violation Q Fxtens'on <br /> O <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/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459:2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!GIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O 1 Other: § <br /> Comments PY'�^ "--f!�f��Y•"'r�- -� dAte• t Ai fai <br /> - - — - <br /> .�/ -tiresvI�� eSc� <br /> op 61 0,- less. is alis Lp u Sc d 'ts g tv_C.w4 s <br /> inspection Form Included:Q v G G} <br /> Comments Included:Q�113— - - I-qO ys - - <br /> sin s Rep' S' nature Phone Number s ector's ' nature Phone Number' <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: E X A I M I P (. 1 Z 3 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />