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r — <br /> U��'ri�(s�S�2 <br /> Waste Tire Survey-& Inspection`Report Inspection Report Number <br /> s`a'e°fcalilernla Survey Form Page 1 1 4 - 1 3 7 3 3 8 6 <br /> CIwMB 191(New Oa011 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- LI r1 ^ �j] Inspection Type (Fill one) <br /> SiteSuffix ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier:.. (A 7�ia 'Y . C k Q CHPQ CIWMB Q Complaint Q'Educational Visit Q Other <br /> Business <br /> -orr�Facility Name <br /> `4,. <br /> I V`Y , d ,ry S Skm S I InBy_ O Ins <br /> pector <br /> G {� C <br /> Physical Address U q � �� <br /> is I oI E 1ra�.o( �- , L✓ ---- - <br /> Street <br /> Lo c kc:()Yd CA- .9 5p37 i <br /> Inspection Date , a O <br /> I <br /> City State Z7P Code Time In Time Out <br /> Business Rep Title QAM 0 AM <br /> m'F 1 0 PM LLJ: 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) + r O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator. Q Outdoor- <br /> GPS <br /> Closed Q Altered <br /> GPS Latitude �.� Q Hauler Q Indoor <br /> 0 ®Inactive Q Truck <br /> Longitude _ Q Planned ®(7. 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 1�N� I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other' eLW V kaKIkfacf r4 Krl <br /> r <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I AHAULING AND MANIFEST REQUIREMENTS Q Notice t3f 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 <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 F>(T) <br /> Q O <br /> 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 I GIWMB 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 Other: §. <br /> Comments D 1h5 CC `J•( t Qi J�(/er1 IW W.tl 1S on <br /> 'res r� tam b Wilms We . �e once- of 'IWi / <br /> No Iris sdbt e ar. ` e Rnco -�u Irk"Va f e l.t),h <br /> a r CbTs rey r' <br /> I <br /> Inspection Form Included:Q <br /> Comments Included:Q ����50� - - 96a <br /> Busi ss s Signature Phone Number Inspector's ignatum Phone Number . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X .A I``R P:'L E: 4 2 3 62081 <br /> ■ While Copy CIWMB Yellow Copy:Operator Pink Copy,LEA ® ■ <br />