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UA Waste Tire Survey & Inspection Report InspectionJiIJA }MA0 . <br /> oaoai <br /> sew°'1a(14`°� <br /> crvvMa ts+(Now Survey Form - Page 1 1 4 - 1 01 0 7 4 4 <br /> Calif°mla Integrated W.V.Management Board <br /> Pati A-Survey. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' n n O � � � Inspection Type (Fill one) <br /> Site Suffix: �hJ l/� / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ,� If Referral,choose referral type(Fill one) <br /> Identifier: N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> or�Facility Name Inspected By Inspector <br /> yVO est a l e ,(1 �Qr1%cCQi Til — I M10 <br /> I eek <br /> Physical Addr <br /> I $S�,o &0aa(LU" <br /> Street <br /> a 1. <br /> Inspection DateS"y,C!_-t0,` C'jr !�-;C)5-1 tte lip(;oe <br /> Time In J Time Out <br /> Business Rep Title 0 AM 0 AM <br /> HLrnand e —��/y�_Lpp J m MOPM <br /> 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I t 215- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> Q Hauler Q indoorPSLatitue Q inactive <br /> F o ®Truck <br /> LonQ Planned Q OTR Q End-Use Q Container I1 171 <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 0 Hauler Q Agriculture Q Shredder ®Other IliyX t �'KC f� Rif t <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459-1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 1 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 Q 1 Other. § <br /> Comments FCuw(&l ( ��l -tnts dah • &6 <br /> aS " gd, 9{1a _ rand grX ice.S -&e a,�d coo not- -0-W?L VAdEl <br /> h ' K30rkrwided. ret re-A2Zn °rz dt's s <br /> Inspection Form Included:Q <br /> Comments Included:® - <br /> Business Rep's S gnatura Phone Number 1 p ctor's 5 mature Phone Number_ <br /> INSTRUCTIONS ON BACK Correct: 9X AO Incorrect- ( M P LIE1 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />