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tee- <br /> Waste Tire Survey& Inspection Report Inspection Report Number ■ <br /> a� Stete 6f MB18litomia Survey Form - Page 1 1 7 - 10 7 9 2 0 5 <br /> CIWMB 181 Waste <br /> ) <br /> Calitomia It grated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) Inspection Type (Fill one) <br /> Site Suffix: �I5 / f 3 S Q / <br /> Q Routine Q Re-inspection Q Referral ®Observation <br /> Local �/' ^�— If Referral,choose.referral type(Fill one) . . . <br /> Identifier: c�f4w/ / `�/ �CStJN 7 _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !J (/ Inspected By Inspector <br /> Physical Address / LPA t /A44z_J� <br /> Street <br /> Sz L',¢ 952/ Inspection Date <br /> City state ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> LE m0 PM m'm 0 P <br /> '—�-(-_— C--'f q �Cr� - �i Nf EST M�►f L <br /> Operational Status Tire Type Business Role • Storage Type,.• <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I*Active Q Passenger . 0 Generator • Q Outdoor <br /> IO Q Closed Q Altered <br /> GPS Latitude Q Hauler. Q Indoor <br /> -' —'� L-I-- --�� Q Inactive I&Truck - <br /> -I — o <br /> Longitude I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Data <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 EXT) <br /> Q Q 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 O Referred I 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 Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> p�r�,e✓�nc,✓ i�s�b��I>ai_I 7J�r.� a.�_,_r�h��//ouJ�� �-�.�_-n <br /> —��' /�•�S/G—�¢_G rli_d� d.S��' �� _ �11/�J�J/��5� �_1��ST_���4 <br /> ,!;c� ��IL.C._N�q.�vl�'(�/_�s !/i�cJ_�/_V_o/�b_/,A-f_'r�t/.s d R\/--�o.✓�c�Ls <br /> Inspection Form Included: Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ - <br /> INSTRUCTIONS ON BACK Oorrect: Incorrect:7(� 0 A AM1 P L E! 1 `Z 3 62081 <br /> ■ While .c f MB Yellow Copy:Operator Pink Copy.LEA <br />