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08129041076 <br /> .rr <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stamoll81(N . Surve Form - Pa e 1 1 2 . 1 0 7 2 8 1 6 <br /> CIWMB 181(NewONg4( Y <br /> C�Ifomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f /) Q I Q ( - D Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: F55 (NV Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> L Inspection Date <br /> /t pG <br /> City State 2TP QJr3�PCode Time In Time <br /> im`"a IIIOu/tJ <br /> Business//Rep Title Q AM Q AM <br /> 0 PM m.m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r Active Passenger 0 Generator Outdoor <br /> Q Closed Q <br /> GPS Latitude L , I I I—I Truck Q <br /> Hauler Indoor <br /> _J J I� O Q Inactive �Truck <br /> Longitude - 17171.1 I� Q Planned i 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 /> i <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 Other L9'oe f '�+9Zati11-G �4tf. J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS __ <br /> V A f 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / EE / 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 EXE <br /> Q Q 14 CCR§19459.3-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 1 Q 1 Other: § <br /> Comments / i <br /> OvT61s <br /> 1 / d <br /> ection Form Included: <br /> Insp Z� <br /> Comments Included: <br /> Q Bus -�jaturg"" Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C f� Ineor ect: X A M P L E' 1 2 3. <br /> ■ White Cop!CIWM Yellow Copy Operator Pink Copy LEA ® ■ <br />