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07354040041 <br /> Waste Tire Survey & Inspection Report _ Inspection RepoltNumber <br /> s�teorcanrarnia survey Form - Page 1 1 1 6 . 1 0 7 3 4 7 9 <br /> CIWMB 781(New..g <br /> Calffamla Integrated Waste Management Board -- -- ---�--- �- --� <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: / 13 .3 i O S 1 S - <br /> _ � ®Routine Q Re-inspection p Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: . (� l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facirlity Name Inspected By Inspector <br /> TA <br /> �� <br /> --. iPhysical Address--- 3 - 10 _J_ <br /> Pi <br /> Inspection Date QI 6 i 10 <br /> Time In Time Out <br /> Business Rep Title ! I 10 AM IJS I (: I O AM <br /> 5 --J®PM L_ , ®PM <br /> a b ���� - SOY Operational Status Tire Type Business Role Storage Type <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> i GPS Latitude Q Hauler Q Indoor <br /> O 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Data 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 EX"n <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/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 /> 1010 1 Other: § <br /> Comments ;? A <br /> �COuir_u.—��.�:t+c�—C"Y-�—'�'LuS— :'- —�-+F�- <br /> _��S -?-AMC o k:.C., <br /> r <br /> Inspection Form Included:Q - ...� <br /> Comments Included:Q v <br /> Business Rep's SI nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 incorrect:�� l`!J EXAMPLE 2 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA © ■ <br />