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•rfr. <br /> Waste Tire Survey & Inspection Report Inspection Rgdil '1 j� t7 <br /> ctrl State of CalHomra <br /> integrated <br /> waste <br /> nagQ Survey Form - Page 1 1 5 - 1 0 10 7 4 5 <br /> Colifomla Inbgrat•d Wash Management Board -- <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details _ _ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: c( ®Routine Q Re-inspection Q Referral 0 Observation <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: - _ Q CHP Q CIWMB 0 Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 153a N• 940cwtwaI <br /> Street Inspection Date O 0 <br /> City rate ZIP de Time In Time Out <br /> Business Rep �j Title 0 AM Q AM <br /> �tOh 1 r0tLL L CjQ m MO PM [T] O PM <br /> Y1111!_ f <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 /> I. 0 Active ®Passenger 0 Generator ®Outdoor <br /> j O C)Closed Q Altered <br /> GPS Latitude L� F1 11 O Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - 0 End-Use Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ®Other `�6tiYJp- r <br /> mac-_''"�-�1_lI�- —✓_1�Q..�_J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-RegistrationlDecal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m I m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E7CTJ <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 40 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators . ®In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments �� � 111S CC: _ SAdQ. -/Iv— fy/Iw4 h-a t<d:kf%ia&-c <br /> aft Ohire PM Srt L e,S s 0.52 1 CPtSrpsd <br /> p��►S�r•?t en <br /> -l- c, CCP- 1 wi ies-F <br /> Inspection Form Included:lO (�9> <br /> Comments Included:® `yy 5793 2- <br /> Business Rep's Signature Phone Number lip,cto ignature Phone Number <br /> 7�p� .-� <br /> INSTRUCTIONS ON BACK Correct: Incorrect:�X(a) v� E I krA IMI P L 62081 E 1 2 3 <br /> ■ While Copy CIWMB Yellaw Cupy:Operator Pink Capt'.LFA <br />