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Waste Tire Survey & Inspection Report InspectionR 70027 <br /> Waste ■ <br /> Sate el California Survey Form - Page 1 1 7 - 1 Q 1 0 $ 5 4 <br /> CIWMB 181 st eM 04/04) <br /> age <br /> Cali,omla Integrated Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 14] Inspection Inspection Type (Fill one) <br /> Sita Suffix: I / I fJ 0 Routine O Re-inspection 0 Referral O Observation <br /> Local /�Q C If Referral,choose referral type(Fill one) <br /> Identifier: Q+Z d L��%r O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Y - <br /> Inspe <br /> cted By Inspector <br /> Physical Address <br /> I Z4�E <br /> Street <br /> Inspection Date <br /> city State ZIP Code Time In ]—ITime Out <br /> Business Rep Title O AM 0 AM <br /> O PM Q 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)' <br /> 0 Active O Passenger ®Generator 0 Outdoor <br /> F—f—'—T T O <br /> Latitude � I I O Closed O Altered <br /> GP$ L O Hauler O Indoor-�'-- -- ��-- O Inactive ®Truck <br /> LongitudeO O Planned O OTR O End-Use O Container <br /> I <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 0 Other I �iLlP�i� {'�CQtssc�e <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AIIHM.11111NG AND MANIFEST REQUIREMENTS <br /> O O Notice Of Violation O Extension <br /> O <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-omplfan ce Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 • 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[I] / m / IE <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or DCT) <br /> O O 14 CCR§18459.3-Retention of Manifest Fors and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred t C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 4aA.7le yl o `-r d LLs�Ci� T Wn G�otl�trQ <br /> o�s /'Aw <br /> ✓rr�l ��. <br /> Inspection Form Included:O ";�_R�p"Srtsli`gnature <br /> n(2--0'1) <br /> Comments Included:OCOCAY�JBPhone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M4 P L E i 1 .2 3 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />