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' 092i0Q��19R <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I 1 - 10 86 9 3 4 <br /> California Ine grat df81Wasee - <br /> Management Board Survey- Form Page 1 i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 14J 19 1 _ [C)A <br /> Inspection Type (Fill one) <br /> Site Suffix: ' �j • Routine Q Re-inspection Q Referral Q Observation <br /> — — v <br /> Local ��, �il\ If Referral,choose referral type(Fill one) <br /> Identifier: Y 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L_35,50 �o.zzzJ x yjC)_�-�_. I <br /> Street <br /> Inspection Date <br /> C_c,� a5d._U <br /> City Stale ZIP Cod.. Time In Time Out <br /> Business Rep Title ^T �I ��0 AM 0 AM <br /> 13i ` ;O PM I I Ali[ 1 1 QPM <br /> kob <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) <br /> v f ®Active Q Passenger ®Generator Outdoor. <br /> ' O Q Closed Q Altered :. <br /> GPS Latitude Q Hauler Q Indoor <br /> -i0 Q Inactive Q Truck <br /> Longitude - 1 , Q Planned ® 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 L it, e� �T� _a�L_I <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility N ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Ex <br /> Q Qtension <br /> 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 Date m / m / E[I <br /> Q Q 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 EXE <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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <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 <br /> ro <br /> Inspection Form Included: Q <br /> Comments Included: 0 - <br /> Business Rep's Sig ature/ Phone Number In a Si to Phone Number <br /> INSTRUCTIONS ON BACK Co ret Incorrect: X A P L 1 ;2 3 62081 <br /> White Cop :CI Yellow Copy:Operator Pink Copy:LEA <br />