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I- Waste Tire Survey & Inspection Report Inspection Re um e ■ <br /> Ir" State o/Galifomia <br /> CM'Me 18 (N.;�,g.l Survey Form - Paye 1 1 1 10 1 3 0 8 3 <br /> Calilomia Anagntad Wast. <br /> 6oartl <br /> . <br /> 'art A-Survev BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- I ^ r7 64 - F07) <br /> i [ 1 O ) Inspection Type (Fill one) <br /> Site Suffix: ( `7 1rJl `7 I ®Routine Q Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> I <br /> Identifier: �tIt, -- 0��. 0 CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facllity Name (� Inspected By Inspector <br /> Physical Address <br /> I 9 9 3 Ln-u �d <br /> Street S �Vrl Inspection Date <br /> I IY�"-` � � I <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleImopm <br /> Q AM <br /> Q AM <br /> Mollie- QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f I 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i i r @ Active 0 Passenger ®Generator 0 Outdoor <br /> Latitude I i O 0 Closed 0 Altered <br /> GPS •L_� 1 '� 0 Hauler l0 Indoor <br /> 0 Inactive ®Truck <br /> Longitude _ I IO 0 Planned 0 OTR 0 End-Use 10 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair (�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 I I <br /> Part B-Inspection of Waste Tlre Dealer,Generator,Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 11:1 / Ll LD <br /> I D 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 10 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or FACT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 10 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 Lit '✓�tL 11 _ - uJI06_ r 6+ ed. /vl <br /> Ce - - a Q. CSt j h v 'ce d e e a <br /> W6 'IV -s a a&e *' "� on. <br /> lc �� �g (�I <br /> e tS'sfern �' ye. u�.e5i . <br /> Inspection Form Included:t�' i <br /> Comments Included:0 " r 1(6����� - ��(/ <br /> Busm s Rep Si�atu?r---� Phone Number Ins _ 's Sig ure Phone Number <br /> • �C� g J l l l III 1 1112131 6208, <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE <br /> ■ Whito Copy:CIWMB Yellow Copy.Operator Pink Copy LEA ■ <br />