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... Inspection Tire Su4by & Inspection Repor Inspection Report Number <br /> -addl State of CaliforniaCIWj'�} �/►i `j7 (4�) <br /> ew 04104) <br /> California Integral d,Was81 tJe Management Board Survey Form - Page 1 I 9 10 ? 2 9 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 5 - © 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: t —�8 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> L y�; - L_- �Ti4Ti JnI I 3 �. _ / O <br /> Ph sica Address � <br /> I 116L) I l 77 I <br /> Street <br /> � A Inspection Date U 5 <br /> City State ZIP Code . Time In Time Out <br /> Business Rep Title AM O AM <br /> OPM OPM <br /> r2 _ _ _ _ <br /> 1. I I <br /> L t�� Operational Status Tire Type Business Role Storage TypeT <br /> Tire Count(Whole/PTE) I I JmT 1-31-3 <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> *Active 0 Passenger a Generator 0 Outdoor <br /> O0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 'e <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / FF] <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § -- - <br /> Comments --7 <br /> F7444 7 E' sfil ,�� f1 -:—�{�7,�,r ✓Pte,v f �f �, <br /> 11-4 T,"ki = c/' �onli F,r M <br /> Inspection Form Included: 0, <br /> Comments Included: 0'', <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> /� E= i 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A M P h 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />