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Waste Tire Survey & Inspection Report Inspection Repo Nu mber4 <br /> ■ tfr- StahB at <br /> Survey Form - Page 1 1 8 . 1 0 1 0 5 6 <br /> 1r Cryy11B 161(New f}Ilee) <br /> callfomia;;"'ted waste Mana""M aoard BLUE OR BLACK INK PEN <br /> partA-SuryeDe — — -- <br /> Business Profile Inspection tails <br /> - Inspection Type (Fill one) <br /> TPID <br /> Site Suffix: a 1 4 ✓ s f O ®Routine Q Re inspection Q Referral Q Observation <br /> -� If Referral,choose referral type(Fill one) <br /> Identifier. ban �a tit,�1'1 CbIA4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> 13aslness or Facility Name Inspected By Inspector <br /> Physical 11�AddreSs -�V►`.`.;�� c��l 3 0� _ 1 oM <br /> 3�a Sog9 — <br /> Street 1/ 1 Inspection Date f� � <br /> 95a��--..J Time Out <br /> ity tare IrP Code {{Timen �10 AM <br /> Business Rep Title I I I: O PM LE; 0 PM <br /> 4�jvk �o►rev✓ '�t) ew�a W L <br /> L. _ Operational Status Tire Type Business Role Storage Type <br /> j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) s ®Active Q Passenger ®Generator ®Outdoor <br /> - - - '.O Q Closed Q Altered <br /> GPS Latitude I i_J Q Hauler Q indoor <br /> Q Inactive ®Truck <br /> - Q ®End Use ®Container <br /> Longitude Planned� d Q OTR <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 L <br /> Pati B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 m m / M <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 1 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> QQ 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q QQ Referred/CIWMB Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 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: § f — — <br /> Comments ) pp CtO'\ YIO Ad `'kg- �if rwi— �� A�'4: Ll SIC <br /> 7r; r w ante F 7Ye <br /> —cru uk r In .moo M Ocvl ire r►� <br /> w astt tine o(.ict 5a.�. 7i�z Ca u fi <br /> p ri_Lte._ CQ rtfe� deo- o w F <br /> 0 12 71$77 <br /> Inspeetlon Form Included:® �, 14 l��Q•�/�6 <br /> Comments Included:® Ins tar's S n 'Ira Phone Number <br /> usiness Rep's Signature Phone Number P <br /> --- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:}�YX( E X A M P E 1 2 3 1 ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />