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uial2v+yvs24 <br /> rrr <br /> Waste Tire Survey.& Inspection Report Inspection Report Number <br /> ;r <br /> State ofCalifornia <br /> Survey Form - Pagel <br /> 1 3 - 1 0 7 3 5 6 7 <br /> CIWMB 181 tew.. <br /> CaliforniaalifIntegrated Waste Manage <br /> ment Boar <br /> d <br /> 3art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I� -V y / 3 (S m Inspection Type (Fill one) <br /> Site Suffix: - <br /> Site Sux: I � � <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local /t If Referral,choose referral type(Fill one) <br /> Identifier: Da4,e+r. ( �*"u•e't7 Q CHP Q CIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By. Inspector <br /> I ��1GCaCC,o <br /> Physical Address I 3 / - I� O <br /> Street <br /> I r»"1 � 4S3L L I Inspection Date <br /> City �P State Zip Code Time In Time Out <br /> Business Rep / Title 0 AM 0 AM <br /> •m•PM m•m 0 PM <br /> _ I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude W,I � Q Hauler ®Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - I— O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 111 111 <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 /> Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealeri Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice of Violation Q Extension <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 D(T) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 /> O O Other: § <br /> Comments <br /> �Ylalo _t.N�1l�a.lrvS2�vt <br /> F <br /> Inspection Form Included:Q <br /> Comments Included:Q °� / — _ - T 4q r-6.6 2- <br /> Busine a 's gAatTre / Phone Number nspect.e Signature Phone Number <br /> INSTRUCTIONS ON BACK I Crect: /ncorrect:�Cq I I EdXIAIIMI P 1L 1 EI 1112131 62081 <br /> ■ White C py:CI V Yellow Copy Operator Pink Copy LEA �� ■ <br />