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��3�, 2G4G�I1b <br /> rA9. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> i7r CfWM(l81(Nfnla Survey Form - Page �. [ 3 - 1 0 7 3 5 7 5 <br /> CIWMB 181 stew nail <br /> Calitomla 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: F/73 7 6 $ 3 j b ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - Ili 4yaY� Q CHP Q CIWMB. Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ <br /> Physical Address fk IiR _ /C,--, Mol <br /> L/)_ <br /> l�w�c�a[a. <br /> Street �¢a <br /> Inspection Date <br /> L— Sir 6utor C-A qS _1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m -m 0 PM m�m ®PM <br /> It,IScTn_---_.�tg. — —I Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only), (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ��I i i�' f I r <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> {{ I I I�O Q Closed Q Altered <br /> GPS Latitude �I I —_I I I I Q Hauler Q Indoor <br /> I_11I_� _ Q Inactive Q Truck <br /> Longitude _ �f L I. �I-- Q Planned ®.OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J <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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 FXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements.for Registered Waste Tire Haulers Q Referred f C-IWMB Enforcement <br /> i <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 C-ompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> G%Crsy�w.��� tmerrt. <br /> Inspection Form Included:Q �r <br /> Comments Included:Q <br /> Business Rep' 3igpature J, Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK7rinff: correct: X a MIP L 1 2 3 <br /> ■ White Yellow Copy Operator Pink Copy.LEA ® ■ <br />