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012620; 0011 ■ <br /> - r Waste Tire Survey & inspection Report Inspection Report Number <br /> rrr. i - Y V V V <br /> rl1 Stats a California <br /> CgW.t d' 8St-wO 96 Survey Form - Page 1 1 <br /> Calffomla integrated waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey_ Inspection Details <br /> Business Profile T <br /> Inspection Type (Fill one) <br /> TPID- ' <br /> Site Suffix: I "1 I / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Cjt /Lt.� � O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facllity Name Inspected By Inspector <br /> ��ti .Sf j�iu s �ar� <br /> Physical Address <br /> Street . _ l Inspection Date a' IM017 <br /> it�-y--r ✓�( )_ State ZI ICCooddee', Time In O AM Time Out 0 AM <br /> Business Rep Title FT ;MOPM PM <br /> � r,Incl <br /> Operational Status Tire Type Business Role Storage Type <br /> _(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r t i ®Active Q Passenger ®Generator Q Outdoor <br /> O Altered <br /> 1 Q Closed O Q Hauler Q Indoor <br /> GPS Latitude _v t J O O Truck <br /> _ _ -7.—.o Inactive <br /> Longitude Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) -. - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ,C�✓y�- .�, <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other IN <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 7A i HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal to Vehicle m / S / m <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EX7) <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Referred I CIWMB Enforcement <br /> Q Q 114 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 Other: § <br /> Comments�� C10p1'+[ n.���TL(!r'_ <br /> `P" J <br /> 1Y�rVt rt5 2- a GtS�S _&N 5 e� —�Dr ✓—��-� CCLI �. 17�2� '$ <br /> 6 t1iC�C� �} ifi��QL�t�10 (4G5 Vl�rrJitS 1/2vt(�pSr �z�'Z _6 D. <br /> v�lc _0�_ 2 l iluivCe s at' 171111 j11y- �Cpli�tt�Yt <br /> Inspection Form Included:Q /�Q —1,244 - <br /> Comments <br /> 1,244Comments Included:® _ho 1 7o-+�7 -s ctor's i nature I Phone/Numberv� <br /> Busines s Signature Phone Number p _ -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 z 3 © ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />