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- «.. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> • pIL State of California <br /> 1r CrWMS <br /> Waste <br /> eManage) Survey Form - Page 1 I- 7 - 1 0 1 3 41 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile �� ^(�1 Inspection Details _ <br /> TPID- t� _ t 6F/] Inspection Type (Fill one) <br /> ffiSite Sux: 1 Q Routine a Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /l Inspected By Inspector <br /> --r-I <br /> ,0_a braJ ChI^ SPS I 3 0l - O r ,Gh►,ti wt Z <br /> Physical Address �� <br /> 1 I `�5 KV- 0� ►'►�ire Ave , _ <br /> 'Street <br /> _/t4Q /wQ� 33Inspection Date <br /> I,nytT G- 9 `7 I <br /> City State Zode Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> D � <br /> 2 �} ® PM K11 <br /> a � ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f <br /> f i f O ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I ,I 11 I IJJ; Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> -� - -i '--- 77--'1 - -T O End-Use Container <br /> Longitude Q Planned Q OTR Q <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I 11 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS Q 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. 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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXE <br /> 14 CCR§ 184592.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§ 18459.3- Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (a In Compliance - No Violations <br /> Q Q Other: <br /> Comments `l'�—� <br /> was riohd <br /> Cli(Lty_ <br /> IF <br /> hCIS a tAAr —� fr �I_e r - u�aSf e- tamp <br /> ! S - f i evt/e�oL h0�e1ev2� n o was fires Jay <br /> ::c � <br /> Q,eV1�l'►'IoV_e d� ►'+'1 Si no Yha n.�fvs+S c �a Va<u <br /> Inspection Form Included: Q Z00 - C <br /> L)rl"_9 <br /> Comments Included: ® 2,Zin, sRp". Signature Phone Number Insp t 's Sign t e Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �j E X A MP L I= 1 2 3 <br /> White Copy:CIWMB Yellow CopyOperator Pink Copy:LEA <br />