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0$n5543�001 <br /> Waste Tire Survey 8t. Inspection Report Inspection Report Number <br /> 5fWMB181 jNm{a0 Survey Form Page 1 1 1 1 0 7 3 4 0 9 1 <br /> CIWMB 181 stew abate) <br /> Calllomia Integrated Waste Management Board <br /> Sart A-Survev BLUE OR BLACK INK PEN <br /> Business Profile. a Inspection Details <br /> TPID- 1-71 <br /> n I Inspection Type.(Fill one) <br /> Site Suffix: ®Routine Q Re-inspection 1 Q Referral Q Observation <br /> Local / �On M ^ � If Referral,choose referral type(Fill one) <br /> Identifier: (V^u„�,',( `^•Tr^^r•` /lam' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U U Inspected By Inspector <br /> Physical Address . 3 1 Q I I �(,��Fri-, I <br /> I ;z 0(P 9 W. LA,_,�s I <br /> Street —1'-�r�- �j J <br /> 1 ' /'L / CJ 30 1 I Inspection Date <br /> City Q (�� / State ZIP Code Time In Time Out <br /> Business Rep Title OA OA <br /> M <br /> QPM :I I 1 OPM <br /> /VaYL eta e /�la!�ih_ 0 W"'r- F i: <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i I I Q t D O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v� ®Active ®Passenger ®Generator ®Outdoor <br /> 1 F1 O Q Closed ®Altered <br /> GPS Latitude , Q Hauler Q Indoor <br /> L1_J <br /> 1111 0 Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 ®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 Data m / m / m <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 for NOV or EXT) <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 I 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 ®in Compliance - No Violations <br /> Q Q Other: §, <br /> Comments �n,, f;,, n �ylc de 0 1X10 �f5 kj✓t /'Qmlivyrj 6,M' ;q_ <br /> Vg .cevuts`)abf`^�rur �-. 7i rQ. ase-0 ►M.Q_:fGtad_s r�Ct scc�s l vi <br /> � P- - _ <br /> ole <br /> Inspection Form.Included:Q <br /> Comments Included:® <br /> Bu nes ep s Sig at a Phone Number Inspectot16nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> X(I) V IIEIXIANMIPI'LIE[ 1112131 6208, <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy LEA �� ■ <br />