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VOL OL V`n9VS3; <br /> i <br /> == Waste Tire Survey & Inspection Report inspection Report Number <br /> ce <br /> 4r State B California S u rve Form - Page 1 I 1 1088261 <br /> r CMatedlW st(Ne.04104) Y ry <br /> -California Integrated Waele Management Boats `�' <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / D © O / Inspection Type (Fill one) <br /> Sit' <br /> Site Suffix: (Ji 11 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: !OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> -7—ire- <br /> Physical <br /> inspected By Inspector <br /> I 4� !re- <br /> I' .^�Physical dress [rY <br /> 1 © 1 �/'�I 1_4A4,N <br /> e-04,0^f 7 - T <br /> Street /j <br /> I �C/ C,4 � r��� Inspection Date <br /> City Stefe ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Q PM �'� QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> b <br /> Tire Count(Whole/PTE) F1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t O V Active 0 Passenger 0 Generator 0 Outdoor <br /> — O Q Closed Q Altered <br /> GPS Latitude <br /> Q Hauler Q Indoor <br /> -- ---- _-_:-- _- - _ <br /> __JQ Inactive Q Truck <br /> Longitude — I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 I <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 Violation xtension <br /> Q E <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 m 1 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 FXT) <br /> Q O - ---- -- ---- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Lags for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 Q1 Other: § <br /> Comments •l <br /> �+y s <br /> _�/_i'_ ►_ - �✓o—✓�o�-ate��/-- c,��,s Ae-r-k,,V_. <br /> Inspection Form Included:Q 1/ nO <br /> Comments Included:Q —��� 46p r6}3 <br /> Businesslap Signa re Phone Number • Inspector's Signature Phone Number <br /> 62081INSTRUCTIONS ON BACKorre Incorrect: X a A4 P ,l E 1. 2 3Whifpy:CI Yellow Copy:Operator Pink Copy:LEA ■ <br />