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■ _. :: 012350 X0005 . <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> - <br /> t r Stau of Caldornia <br /> ttr CIWMa181te:.04J04) Survey Form - Page 1 2- 1_0 10 5 1 1 <br /> CaSurvey_lifornia integrated Waste Management Board <br /> Part A• BLUE OR BLACK INK PEN <br /> _ <br /> Busine� inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '(,�y( ��a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C Inspected By Inspector <br /> Pions / QKa� �arrJP.r S i 3 - t a 1 s —9?-- I <br /> Physical Address L L�:'J_ i,L� <br /> Street l <br /> Ttrd V+ 96_& Inspection Date <br /> City — Wale P ode <br /> Time In Tr Out <br /> Business Rep Title 0AM 0 AM <br /> TrK�C Pji.nal <br /> 0PM ' 0PM <br /> Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> + 1 ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude ! I O Q Closed Q Altered <br /> GPS Q Inact <br /> N +t <br /> I J Q Hauler Q Indoor /r <br /> __7 _ ,r_- •- —-I --,iii__ID ive ®Truck <br /> Longitude _ Q Planned ®' T Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4D 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 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F>CTJ <br /> Q ® 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIW MB Enforcement <br /> Q Q 14 CCA§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: § I <br /> �. <br /> CommentsQ�� Qr_ S Gl�i/Sok(� /f►' <br /> r i _ ._. EDT and ax_ esfS hota✓Gt.�-ladle tDr' j <br /> �CnS�2c��on . <br /> � <br /> A le, CC' J Sf <br /> Inspection Form Included:Q <br /> Comments included:® 9 <br /> sin as ep's gnatum Phone Number 9� bto 1 nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:0& N1 E X A P ILJEJ 1112131 <br /> 62081 <br /> ■ White Copy.CrWMB Yellow Copy.Operator Pink Copy.LEA © ■ <br />