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Waste Tire Survey & Inspection Report lnspecti <br /> State of Survey Form - Page 1 1 3 - 10 7 9 1 0 2 <br /> 0410.) J <br /> Callfomla InteCIWMB 191(Naw grated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> I TPID 1 O $ - O Inspection Type (Fill one) <br /> Site Suffix: l o ®Routine Q Re-inspection Q Referral Q Observation <br /> Locala If Referral,choose referral type(Fill one) <br /> Identifier: SQ'(\ SO clgwYA County Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> L_S_-�ocA'�oa 0� 9520.3 <br /> City State ZIP Code EJ: <br /> Time In Time Out <br /> Business Rep Title M 0 AM 0 AM <br /> 0 PM 0 PM <br /> A)AL <br /> �e�� — Manan-ec-- <br /> Operational Status The Type Business Role Storage Type <br /> Fill all that a Fill all that a I ^ (Fill one only) (Fill all that apply) ( apply) ( apply) <br /> Tire Count(Whole/PTE) <br /> ' `( S Active Q Passenger t®Generator ®Outdoor <br /> I I I I IO Q Closed Q Altered <br /> Latitude <br /> GPS L I i. � Q Hauler Q Indoor <br /> Q Inactive S Truck <br /> I i Q End-Use Q Container <br /> Longitude - I � � I.I I I I Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 t <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other L_-Tpu� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXI) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> .0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 e in Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> _or{kreo�p� aCRrns al�se1�v_e-o� C� L—o.rQ G �f�n w�atrr�a�n-ed <br /> -- <br /> Inspection Form Included:Q <br /> Comments Included:QK.1.1.1ignature Phone NumberBu—nessR 'sSi , Phone Number _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JE�JXJAJ�MJPILIEJ 1112131 <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® . <br />