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yy�!te Tire Su" .ey & Inspection Report Inspection Report Number <br /> '-'=� ifornia <br /> CIWMB 04/0 <br /> Integrated181 <br /> diWaseeManagementBoard Survey Form - Page 1 1 J 1006 "111 f <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D 4 �- 2 - C I AP*r6utine ® Re-inspection Q Referral f Q Observation <br /> Local _ 7 ` If Referral,choose referral type(Fill one) <br /> Identifier: yah , ZsA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> w\G',vk�-C.-crti 1 v�� ' - <br /> Physical Address ? - ` J <br /> `V\ai w -5 <br /> ( Inspection Date G / <br /> Time In Time Out <br /> Business Rep Title ^OC V'. ZV.-7— 0 AM 0 AM <br /> r U O ®PM J a ® 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 /> f f ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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 apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body * Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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 <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 /> ----- - <br /> Q ® 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - ---- — <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 <br /> ® In Compliance - No Violations I <br /> O O Other: § l <br /> Comments <br /> F1'- �` �.c�v��NC�f k\ ' > <br /> L LL_,-k, L� <br /> t� CAAA <br /> a1. 4, am L-(-,, �7 �III.L �m� <br /> Inspection Form Included: Q l j, <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number I spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ,�,"I 1 L 3 62081 <br /> ® White Copy:CIWMB Yellow Copy Operator Pink Copy LEA <br />