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0��29Q4�942 <br /> a <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Sta`a°"afiromla Survey Form - Page 1 1 8 - 10 7 3 4 2 31 <br /> cnvMa tat rNaw oaoal �/ <br /> Cali/omla Inlagrated Waste Management Board l <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> site suffix: C IV ,3- O Y 3. S O 0 Routine O Re-inspection . O Referral O Observation <br /> Local _ If Referral,choose referral type(Fill one)- <br /> Identifier. .. �(/� O CHP O CIWMB O Complaint O Educational Visit .O.Other <br /> Business or <br /> Facility <br /> Ny Name (/_Y Inspected By Inspector <br /> `N <br /> Physical Address —— V v 3 1 — / v Lt <br /> \J <br /> I /L10 I �, reser 4ve l <br /> Street <br /> SC ^ n !E�( Inspection Date 7 <br /> t State Time In Time Out <br /> Business Rep Title O AM O AM <br /> L.AL <br /> � "!— on----��I A. — I _l V.ls[G4Lk�I GI/ � m.m O PM m'm O PM <br /> Operational status Tire Type Business Role - Storage Type <br /> Tire Count(W holelPTE) t (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> ( l_.t• ` r 1� ®Active O Passenger 0 Generator 0 Outdoor <br /> GPS Latitude J j� � �0 O Closed O Altered O O <br /> U Hauler Indoor <br /> 0 O Inactive 0 Truck <br /> I . <br /> Longitude — I-1-� O Planned O OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,-Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§.18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 1010 1 Other. § <br /> f.�, G / /^ <br /> Comments �c,, /;,_ i�.S /_ r � E�r-F BTU/1 — ° <br /> � V K Ralw"o-n <br /> c e (�tGc�r� _ erJ i uXe ire dsj <br /> 0 ° ('TL "uuFe_� Corwtis yiowed . Nn ✓irll&Koy6 5 yLA_feol, <br /> 43 11 <br /> Inspection Formis Included:Q�11'I� L ' 2 q' gqg1gyD &g r 9& <br /> Comments Included:O M1/ y <br /> Business Rep's Signature Phone Number Inspector Signature phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � X A 62081 M P L E 1 2 3 <br /> . While Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> U <br />