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' [1�1 �1U]tJUl ] <br /> == <br /> EL <br /> eee: Waste Tire Survey & Inspection Report- Inspection Report Number <br /> �I State of California <br /> CIWMB 181(New Manag) Survey Form - Page 1 1 5 - 1 0 7 9 3 4 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: FoTF� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SL(n W; �u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name w Inspected By Inspector <br /> AS <br /> Physical Address , I & Lb �� <br /> Street �� 531 <br /> w / ,. n --�]� Inspection Date <br /> City-- �-t.[� state ZIP Code Time In Time Out <br /> Business Rep Titl/e10 AM 7 <br /> /'�/�, 6 AM <br /> lflb] 5 5 O PM I O Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T i f *Active ® Passenger O Generator Outdoor <br /> .Latitude I i � O <br /> Q Closed Q Altered <br /> GPS I_--� `-� • ! ,__I Q Hauler Q Indoor <br /> O Q Inactive. Q Truck <br /> Longitude - I I I , I + _f` j Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) . <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q" Q 14 CCR§.18459 -Responsible Entities Complying with Manifesting Requirements DaV 7 <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 Exrl <br /> 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 1 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 Q In C-ompliance - No Violations <br /> Q Q1 Other: §. <br /> Comments 0�--�n �— jckt- - -. d �nl (� - w.LI.S� — --�s O�,c�►�--—av�.�__w_ <br /> —19.12—_ora _a_c�I -aoo_y—E <br /> rn ` �; +() h r <br /> e,��lcu-f'�' -- —onSWe, e� <br /> Inspection Form Included: Q <br /> Comments Included: -� •• —o2-�{=!- Lkl <br /> Business Rep's Signature Phone Number Inspector's S' nature V. P e Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: F X A M P IL1E 1112151 <br /> White Copy.7 <br /> Yellow Copy.Operator Pink Copy.LEA <br />