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err. <br /> Waste Tire Survey & Inspection Report InspectioMIRMU <br /> State rrr. CfWM of California <br /> Survey Form - Page 1 - 13 - 10 7 3 4191 <br /> CIWMB 1a,(New oa g y n <br /> California Intagratad Waata Management Board `�' <br /> Part A-S_urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 1 TPID- / ; 0 3 3 LOE, <br /> Inspection Type (Fill one) <br /> 3 <br /> Site Suffix: I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: L*PL� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I. eded ey Inspector <br /> Physical Address J?L Fct] - [jj�al <br /> gad F� -tVVV r' <br /> Street �ry/� Inspection Date <br /> cityState <br /> --- J- C+- — ZIP Code Time In Time Out c, <br /> m7� <br /> Business Rep Title O AM 0 AM <br /> poi_ N-rllol s--- --���zcl�l��i - --!/Y.6 0PM OPM <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' O 9 Active Q Passenger ®Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude ` —LJ Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - I I I I I Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) l <br /> Q New Tire Dealer Q Auto Repairt ®Government Q 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 ®Other &S �f � <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A AULING 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 / m / ID <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/or NOV or EY77 <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/C-IWMB 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 Other: § <br /> Comments �hsit qo ' (� yl LL L MOP <br /> C yiTCeQ <br /> Aa -fir'es• CIZ forwis I, We_d. Vtmdor 10 dutnqe 600n . 7Ire <br /> a*vL s e o V• IOLA n A crest r <br /> Inspection Form Included:Q y �� <br /> Comments Included:Q �O <br /> Business Rep's Signa ure Phone Number Inspector's ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: I 1EjXjAjMjPfL1E1 1112131 <br /> 62081 . <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />