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_ U�� iItl4U0�3 <br /> Waste,Tire Suoey & Inspection Repor Inspection Report Number <br /> State of California <br /> California Int Med 81(New WOW . Board Survey Form - Pa g e 1 - Il 10884 5 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � O [�Jj] <br /> _ � ( Inspection Type (Fill one) <br /> ffiSite Sux: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 1 If Referral,choose referral type(Fill one) <br /> Identifier: sa'(N V (�n �� Q CHP Q CIWMB Q Complaint Q Educational Visit. Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AtJdress 171 _ Loill L�.J`kJ`-'` W A� i <br /> Street m � �L1J <br /> Inspection Date a <br /> j <br /> City State Zlp Code Time In <br /> Time Out <br /> Business Rep �1 Title0 AM 0 AM <br /> e PM O� PM <br /> _o . . . __ivQ�,'_� ��Opera11tLio^^_nal(Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> U <br /> 48 Active ® Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . i Q Hauler Q Indoor <br /> -- — - ___j <br /> Q Inactive Q Truck <br /> Long' _ Q End-Use Q Container <br /> Longitude i 1 � � Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 FacilityENFORC-EMENT STATUS <br /> V M HAULING AND MANIFEST REQUIREMENTS <br /> 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 O . 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 EXE <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O�r, <br /> O <br /> ` :CCR§ -Manifest System equrements for Tire Dealers or Waste Tire Generators <br /> 14 18462 MRi <br /> ®In ComplianceViolations <br /> '`Other: <br /> O O' § <br /> Commentst�0c— v �(.- G K - lUt1�21 n - <br /> CA - I�rc-_QLC <br /> Inspection Form Included: Q Q <br /> Comments Included: /f IJ <br /> Business Rep's Signature Phone Number Inspe ors Signature Phone Number <br /> INSTRUCTIONS ON BACK C rre li correct: X( P L E ri .2 3 62081 <br /> - k - <br /> White py:C M Yellow Copy:Operator Pink Copy:LEA <br />