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���5604b06g <br /> Waste Tire.Survey & Inspection Report Inspection Report Number . <br /> ■ -,rrr stateofa 16cellfo <br /> 1(Newmla oaed) Survey Form - Page 1 14 - 1 0 7 3 3 2 0 � <br /> CNVM <br /> California Inte6ratad Waste Management Board ? <br /> Part A-S u rvey BLUE OR BLACK INK PEN y <br /> Business Profile Inspection Details <br /> TPID- ' ! a _ o , Inspection Type (Fill one) <br /> site Suffix: to ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: : y9 C � Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> BussiQin��ess or Facility,Name`//' � �n Inspected By Inspector <br /> Ll�I_ RSI COu� - 16J _ <br /> Physical Address U <br /> L-33_o aha*.�- sa- I <br /> Street rf �nu1 <br /> Inspection Date <br /> 6�tdcL <br /> tty State ZIP Code Time In Time Out <br /> Business Rep Title :m O AM m m O AM t <br /> O PM O PM <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) ! '1 I I !r 15r� I Sf <br /> I ®Active ®Passenger i®Generator ®Outdoor <br /> O QClosed Q Altered <br /> GPS Latitude Q Hauler Q Indoor f <br /> -- O Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> -[1—= , <br /> Business Type (Fill all.that apply) <br /> is <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 O Shredder ®Other <br /> Part B- Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORC-EMENT STq�TiU-S <br /> - <br /> - - <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 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 I' <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> 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 RaUA-�� /n SIA'eC_ LLy1,L S e I Yk S TZL(il_LLI'Gt kas Acit—Aad; sPoScd of G&ACt_ Ia S-- iAs_j19cGh 6-1j. CiC. Vj&A)-r_d FDr I oLt tircS <br /> rVI <br /> ✓ed oh jz//8/o( �'+L �3�f�r ro 71. �.. <br /> s c� . kj/) vpa <br /> Inspection Form Included:Q <br /> Comments Included:Q —----- w - q,96: <br /> usl c ' ignature Phone Number Inspector' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct�Incorrect: i X A M � <br /> P 0 1112131 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator - Pink Copy LEA ® ■ <br />