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r:y Waste Tire Su&y & Inspection Report4Inspection Report Number <br /> State of California j[�y <br /> CaliforniaInCIWMed,WasNeManage) Board Survey Form - Page 1 I - 10 !7 2 8 /V''yJ <br /> �# <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection� - � � Inspection Type (Fill one) <br /> Site Suffix: �-7/ Routine 0 Re-inspection 0 Referral 0 Observation <br /> - Local !-- If Referral,choose referral type(Fill one) <br /> Identifier: J J`A (c 0A)-1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address / / (t i ( F ��(F A <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title -��O AM O AM <br /> �< r / / W • �' 0 P QPM <br /> j t I Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 15 ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> � D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End Use Container <br /> Business Type (Fill all that apply) <br /> iu <br /> 0 New Tire Dealer 0 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 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / M / m <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 Tri 14 CCR§ 18460.2-Manifest System Requirements Logs for 3ears <br /> O O 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 /> 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 <br /> ,., %lt�i_�� , ! I �161r��1(�c s ��?r <br /> A) , . r� <br /> 114- 0�14A 5. <br /> t 12 Al <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> —` 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X A . L 1 t ; 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />