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fspq, Gn AltAY 76 <br /> Waste Tire Survey & Inspection Report Inspection <br /> ReportNumber ■ <br /> ii State of California - I 1 1 O H H 1 J <br /> CWMBgmte 181 asteManage) Survey Form._ -Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O _ f Inspection Type (Fill one) <br /> Site Suffix: *Routine Q Re-inspection Q Referral Q Observation <br /> Local ec If Referral,choose referral type(Fill one) <br /> Identifier: e tj JQAtu;N 6 Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T _ Inspected By Inspector <br /> Physical Addres� 3 1 0 ' <br /> Street (� <br /> Tom, <br /> Inspection Date <br /> I � C� g s3 36 I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I O AM Q AM <br /> Q PM 'I O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> . !O (Fill one only)- (Fill all.that apply) (Fill all that apply) .(Fill all that apply) <br /> Tire Count(Whole/PTE) t t <br /> Active Passenger •Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS j• Q Hauler Q Indoor <br /> —— - -- - Q Inactive 10 Truck <br /> r - ----- -0 <br /> Longitude ij ! Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-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 /> p Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> VA HAULING ANB MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 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 FXT) <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 t <br /> AA - <br /> _ _Q t.Joa- � fv�.t-.'- On/s ii74C <br /> NO <br /> tw.snn� rte' ClC !'l <br /> lvCs.� olt3_ �y �cX Na Vc °�'�-S--oIL �K.S NO <br /> Inspection Form Included:Q A ,/��� <br /> Comments Included:Q a^""t Tb <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orre Incorrect: [ !( A P LIE[- fl 2 3 <br /> ■ White C y:CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />