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', .. 09091040451 <br /> Waste Tire Survey•& Inspection Report Inspection Report Number <br /> State Ma"'lf°'nla Surve Form Pa e 1 1 6 - 1 0 1 3 5 8 3 <br /> CIwMB 101(New nage Y <br /> • California Integrated Waste Management Board , <br /> Part A-S u rvey BLUE OR BLACK INK PEN <br /> Business Profile ; Inspection Details <br /> TPID- / - O Inspection Type (Fill one) <br /> Site <br /> Site Suffix: wl�] ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: `y�,�, J a C 0 Q CHP• Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph_ysfcal Address �G I 3 Q a <br /> Street <br /> � Inspection Date � � If <br /> ova q 5o_Co I l I i <br /> City State ZIP Code Time In Time Out <br /> Business QRep C►T�itle 1 0 AM <br /> 0 PM WPM <br /> 5 C OA � <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE Djj _ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` ,L r �j�' ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude F_J I mI. Q PlannedQ OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair .®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 _ENFORCEM_ENT_STATUS _ <br /> V A I 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 <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 DCT) <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 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 ®In mom lion e - No Violatio s <br /> Q Q Other: § ^, �, �..�,S <br /> Comments �wl t e '—�K6f�Lt�(L'OK Iy✓ kM p <br /> ?� G_tIa s f� SII 5 O►1 �l, , �w�wt� tDl c s�t oo. /JJ& s tvz`c <br /> _ tV'P_ sk to , .lher rS atje,� .For 4aL _�,u4-Sfi- It-es-0 CZZS <br /> yr 3 e�s ✓1 & Vi off :oar s <br /> Inspection Form"Included:.Q C�GI�Y 45q�xa4P CzD <br /> Comments Included:Q - <br /> Business Rep's Signature Phone Number .Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXto 62081 <br /> 1 2 3 ® ■ <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:py:LEA LEA <br />