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07:354040O52 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr SrNMB1alifornla Survey Form - Page 1 12 -_1 0 7349 1 <br /> CIWMB 191(New nage <br /> Galifomla Integrated Waste Management Board -. <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection i Inspection Type (Fill one) <br /> Site Suffix: <br /> L 1_1_ <br /> � 3 �- ' 1 J - i __j ®Routine Q Re-inspection Q Referral Q Observation <br /> __ - T�_-1_ J <br /> LocalI I If Referral,choose referral type(Fill one) <br /> Identifier: L J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> mzi <br /> _ r <br /> Physical Address I- I I Q I I L <br /> I't�W�—Mdk <br /> Inspection Date —�, ��1 �� <br /> �- -c-r S 3 '---I Time In Time out _ <br /> Sldre ZIP-nde _ <br /> Business Rep Title ff i 1 0 AM I 1 �I O AM <br /> --- <br /> - - PM <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 /> ®Active Q Passenger ®Generator M Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive 0 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 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS, <br /> V 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 /> 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 O 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 Ek7f) <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 O 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 /> I`Ax•#-de <br /> TTM_. -- <br /> - S tri✓aZ�er—(/Ix,tea/ ,� ..r�-_/1/cLfnf— �frr+ -c��/r. <br /> _�o f1-ter a_1r;_Ses:►r_cd�_si�r�v:oL12�'isx_S <br /> Inspection Form Included:Q /�;`eAi N• t `�,f <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:�(� l�J I: X A M P L E 1 2 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> I �_ <br />