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r�- <br /> Waste Tire Survey St: Inspection Report Inspectio 817ePMAUIJe� <br /> State o (rna Survey Form - Page 1 5 - 1 0 7 9 Q 0 <br /> CIWMB 1811e1(NNew 04104) <br /> califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,� I�q / Inspection Type (Fill <br /> Site Suffix: L 1.3 i I • b Z ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -���y;y� � � Q CHP Q CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address c' O <br /> rzy I 2 I n �7 <br /> _t.2, I o T,1_C.7_ AVd <br /> Street <br /> Inspection Date <br /> liry —1 Y ----"--- q x'39—e Time In Time Out <br /> Stafe ZIP Code <br /> Business Rep Title [i]: O PM 'm O PM <br /> - - Operational Status Tire Type Business Role Storage Type - <br /> Tire Count(WholeiPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active O Passenger Q Generator Q Outdoor <br /> j !0 0 Closed O Altered <br /> GPS Latitude i I i I O Hauler O Indoor <br /> ®Inactive Q Truck <br /> 1Longitude ( Q End-Use O Container <br /> I � i �Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler 0 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m / m <br /> O 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 EXT)- <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> 10 1 Q 1 Other: § <br /> Comments r <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number nspector's Signa re Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: (� E X P62081 <br /> A M 'L E; 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />