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1/-Irr� <br /> � <br /> ����0I <br /> Waste Tire Survey & Inspection.Report Inspection R �P um er <br /> ru. <br /> State of Calilomla Survey Form - Page 1 1 - 1 0 1 3 0 9� <br /> CIW MB 1a1(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID. Inspection Type (Fill one) <br /> Site Suffix: 1 g 3 3 3:1j] - I®Routine Q Re-inspection Q Referral Q Observation <br /> LocalH Referral,choose referral type(Fill one) <br /> Identifier: tS(� J—&A_U_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Tim D awi-"Ps Pro��i eS _ <br /> (Physical Address <br /> aa�d C� Cts <br /> (Street <br /> Slyckfvh C4 q CH Inspection Date <br /> City Slate Zip Cod& Time In O` TimeOut <br /> Business Rep ` Title 1'� :MOAM 0 AM <br /> h <br /> Tom J7lu'u,�5 Vv�✓� I m• 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> TireCount(Whole/PTE)' f O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t I ;i i ®Active ®Passenger ®Generator ®Outdoor <br /> 1 <br /> -1I rI — —_ -- -1—�0 <br /> GPSLatitu0 <br /> Q Closed Q Altered d <br /> Q Halder I <br /> Q IndoorE -___ -- Q Inactve Q Truck <br /> LongitQ End-Use Q Containude <br /> er IQanned <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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 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 Data <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIW MB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance • No Violations <br /> Q 1 Q 1 Other: § <br /> Comments Rn . Nf WdS <br /> �Q�d wu <br /> 101ro _ o man _ e re ayczJ a ovi fie. '4/c 1f�CCR f$`f(pa - lYlart <br /> F1tS S s+ 'remands— re ran rhes±sir e sc s .fog- 3 <br /> Inspection Form Included:O ��/�,�i /vrrnn <br /> Comments Included:® .� t'/Di r L Eb <br /> Business Rep's Signature Phorte Number n _ctor' nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:10 Incorrect:NO E X A M PILIE1 111213162081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />