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0 Waste Tire Survey & Inspection .Report. Inspection po Number <br /> ree_ <br /> stareof California <br /> ('iMVMB 181(New eCfoA) Survey Form - Page 1 1 9 10 7 9 1 16 <br /> California Integrated Waste Management Board- - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I� � J I J � � O / ®Inspection Type (Fill one) <br /> Site Suffix: I , I J Routine Q Re-inspection Q Referral Q Observation <br /> LocalJo /1 If Referral,choose referral type(Fill one) <br /> Identifier: ti (� Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> &b`S AdD Cu-`' l l - rase i <br /> Physical Address <br /> o A LP (NQQ Sfi l -- <br /> st,eet <br /> I L 0c)` O I Inspection Date <br /> City / J C�State ZIP Code Time In Time Out <br /> Business Rep Title m'm 0 PM 'm 0 PM <br /> -- <br /> " --- "- —"- ------- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply)' <br /> Tire Count(Whole/PTE) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> � <br /> Longitude - I I,i i I � 711' <br /> SI1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®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 Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use.Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IU <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required(or NOV or EXTJ <br /> O O - - - -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O 1 O Other: § <br /> Comments �u�R- i Cay 01 &n /k'z. ; <br /> f p`_1 (j <br /> - G 5e S10.DQ ta_ 71r e- bi S fbd a 40r 're '1- <br /> YY1a.wi s+ forms viewed • 9Je) L/;nk (z s nof'� <br /> Inspection Form Included:Q 333- / 906 <br /> Comments Included: <br /> ness Re —sSignature Phone Number Inspector's Sig re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E )( A M P L E 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />