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�Q2���AQ645 <br /> = e . Waste Tire Su 3y & Inspection Report Inspection Report Number <br /> State I'Callfornia California Integrated clwM Was181 te Management Board Survey Form - Page 1 -1086979 i <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � 5-1 � � �:11 <br /> Inspection Type (Fill one) <br /> Site Suffix: of Ll ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: � j`QC Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L Co 7rvG�_- _tlV4e v i CQ_ <br /> Physical Addresfj ✓ 0 <br /> Street <br /> Vio c o, �' Inspection Date <br /> City j State ZIP Code Time In Time Out <br /> Business R'etps Titles [�E/j ; 2! O ®PM 0a y �i ® PM <br /> l - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r �) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / d ® Active Q Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> - --- - Q Inactive Truck <br /> Longitude Q Planned Q OTR ® End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ® 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 Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility NENFORCEMENT STATUS <br /> V Miff. AND MANIFEST REQUIREMENTS <br /> O O Q Notice of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F�XT) <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 t C-IWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 4- ® In Compliance No Violations <br /> Q Q Other: <br /> Comments C.f16� ` liS �lU/eS 1 F•., n` q e, <br /> ' V W l �� _ <br /> _� r4-�� fir �,,,C-j'� __bl e S, +�aree eCi�� 1p1� t� kph <br /> (tib jor -[ t S r <br /> �Myls C S v i S e S <br /> Inspection Form Included: Q q ,C7Comments Included: Q <br /> Business Rep's Signature f Phone Number Inspector's Signa re Phone Number <br /> INSTRUCTIONS ON BACK Co rect� Incorrect: 62081 <br /> EXAMPLE: 1 ;Z 3 <br /> White Cop CIW Yellow Copy:Operator Pink Copy:LEA <br />