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jWaste Tire Survey & Inspection Report Inspection Re�pd��Nulilb�e16StateB CaliforniaBoaSurve Form - Pa e 1 6 0 1 7 0CIwMa 181(Na.041 4) <br /> California Integated Waste Managenwnl b <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / - 0 Inspection Type (Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local � � If Referral,choose referral type(Fill one) <br /> Identifier: fa-4 p/f7r2 jf z___0 y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busiinnests or Facility Name Inspected By Inspector <br /> I L, G. Qr,,11K C��-7'c'Cvrr I _ <br /> Physical Address F3T91 t/ C / Juaw j,I.i%kwt!� <br /> I Aaw <br /> Street <br /> Inspection Date <br /> I 7 I Time In Time Out <br /> City ate 1P e 0 AM T <br /> Business Rep Title EJ: <br /> m 0 PM l l ' T 0 PloM <br /> i t Operational Status Tire Type Business Role Storage Type <br /> j I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; 1 5- <br /> r Active •Passenger 0 Generator 0 Outdoor <br /> r—T ) I Q <br /> GPS Latitude Closed Q Altered <br /> L I I,I I ; O Q Hauler 0 indoor <br /> IBJ L _ ,_ O Q Inactive Q Truck <br /> Longitude - I l I I I t I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) f <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 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 I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ,HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 40 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0- PRC§42956-Registralion/Decal in Vehicle <br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateMO31 [4S] / [�7 <br /> Q Q 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § _ _ �j <br /> Comments 0�, , GI/� �4G#/ 1''Ct6* r 4ty /�o f(�at/; <br /> 'PeeX1.,2 953 �ifr`�c�S= kr;�lz Al..Akzv L <br /> je <br /> Inspection Form Included:Q /� ,Kat XR,97 <br /> Comments Included: usiness Rep's Signature yC7 Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(1) E X A M P L E 1 2 3 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />