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Waste Tire ey & Inspection Rep Inspection Report Number <br /> a <br /> State of California . <br /> CIWMB 181( e ) Survey Form - Page 1 1 4 1 0 2 6 6 7 6 <br /> California Integrated WasttManage <br /> Waste Management Board - - - <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile ispection Details <br /> TPID- 2 n1 ,311 <br /> /� Inspection Type (Fill one) <br /> Site Suffix: I 13 C) ! - V IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S I,1 J uw+ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name��NV <br /> Inspected By Inspector <br /> N or-I i'W(L Di sfrlbt�� ion► — <br /> Physical Address 3 �' - J{YZ Y'�I kL t I L <br /> Street <br /> t Inspection Date <br /> � ,�I / 2 U(r <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleO AM O AM <br /> C' Lon e i � � �OPM FTOPM <br /> Operational Status ire Type Business Role orage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/ TP <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude m �F170 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that app.' . <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q 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 (D Other I ��r : l t r, I <br /> Part 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q In Compliance - No Violations <br /> Q Q Other: § ( , <br /> CommentsCI I�}l ty)a tCt <br /> hPk((.P c( . 1/t �j`,t-e ar P k1j V ej t kU(t ; rI?VV(UVeGf tVvl(-Ct <br /> P-)ravAV100 1 C , In lir(S un SJf ct(E Lf. �ti1P✓�►t'✓iC'H V,�P(((LP61po S <br /> Ly).- <br /> nsoa ion Form Included: Q quo <br /> � � - <br /> Comments Included: O - <br /> Business Rep's Signature Phone Number. Inspector's Signaturen__ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E-,'xTA hl IP `L El t 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />