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osog�c�o�az <br /> Waste Tire Survey.&.Inspection Report : ,Inspection Report Number -, <br /> CrMB1eu,or�u Survey Form - Page 4 1 3 1 0 7 3 3 6 0 <br /> ,wula,e,(114"egos <br /> c+ummlalmsyrau0wae,o6,anageme, m9oart, <br /> Part A. BLUE OR BLACK INK PEN <br /> Surve <br /> Business Profile Inspection Details <br /> TPID- I 2 _ I Inspection.Type (Fill one) <br /> Site Suffix: •7 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier ��� Q CHP Q CIWMB p Complaint .Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I D f} W iRN - I o <br /> Physical AddressY <br /> I 1 SOS E brctic�a�t I - - <br /> Street Inspection Date <br /> I LOC&f&v( Cil- '� �-7 <br /> City ,�',iy�p ;L Inspection <br /> Code 1 Time In Time Out <br /> Business Rep ,A I l r v Inm n �'^'T�h/le�^s �/ O AM O AM <br /> Clev F- m• O PM m•m 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) I O <br /> Active QPassenger ®.Generator Q Outdoor <br /> - - — — -- — O Q Closed Q Altered <br /> GPS Latitude W, Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR o End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer -Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q DismantlerQ 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 Q Other I I <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATiUS <br /> HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> o 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 (Requi ed for NOV or DC7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> o 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 /> 1010 1 Other: § l <br /> Comments <br /> os iVW <br /> iP S S�orecQ on Sat, CSL S (� i <br /> ��-s t I/I�iLSa►_L' l�A ' —i��1 On Sc'fe. �O ✓i0 <br /> Inspection Form Included:Q ,��^2 <br /> Comments Included: YJ �//f� -`J�J1 ������� <br /> Q Business RepSO t Phone Number Inspector's gnature Phone Number. <br /> n -- - - --- <br /> INSTRUCTIONS ON N BACK Correct: 1,Got, FE X A[W[PL I 12 3 62081 <br /> . White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />