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....'l?�1:.�...�.�-�....�::1.. ,-..__.__r so_ 4i:[s!_......-.� .... ...._.-:........ ........ . ....._.__..-.................. _ _ <br /> i::- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> "�' CIWMB 811(N California <br /> am Survey Form - Page 1 Il - 1143960 <br /> Califorrvey <br /> nia Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> Part A- Su <br /> Business Profile Inspection Details - <br /> TPID- I , h Inspection Type (Fill one) <br /> Site Suffix: I u S " I 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S �(� J 04, L4;/1 Cb��k Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -TC2 A" �I , Ind 3 5 - l � l <br /> Physical Address Px{> cc <br /> Inspection Date 5 <br /> 1l' CA J U Time In Time Out <br /> • S V J Q <br /> Business Rep Title <br /> AM 0 AM <br /> 41 <br /> PM PM <br /> C car A'h <br /> - -- --- - - - -- - - <br /> Operational - - - <br /> Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � � 1`IY1 <br /> 0 Active ® Passenger S Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 If Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FU <br /> / m / m <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 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 • In Compliance - No Violations <br /> Q Q Other: § l- -- ---- <br /> Comments (7 I t s ��` � A4,n () � Y1_LS <br /> 0V 11 Ok b <br /> Inspection Form Included: Qi <br /> Comments Included:il.N <br /> siness Rep's Signature Phone Number nspe�"�,Si'gnt.rePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X . �] E X A White Copy:CIWMB Yellow Copy:Operator Pink C <br />