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08 8MANbi 6 ■ <br /> Waste Tire Survey 8h Inspection Report- InspectiDn epo umber <br /> 11 errrMBIfilNomle Survey Form - Page 1 14 - 1 0 7 91 6 0 <br /> Cg.t 781O.M..9 <br /> Gllfomla Inrsyrated Wasre Manapemenl Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 3 ,/ ` O / D / Inspection Type (Fill one) <br /> Suffix:Site 'T .Routine Q Re-inspection Q Referral Q Observation <br /> Local /1 If Referral,choose referral type(Fill one) <br /> Identifier: SA-jQ CHP Q CIWMB Q.Complaint. Q Educational Visit Q Other <br /> Business or Facility Name If <br /> Inspected By Inspector <br /> I. 57Tis� ►�Or(.t �RQ I 2 <br /> Physical Address <br /> 3500 A*,,,. '►�Ga?�a Wim-..( I - - <br /> Street inspection Date ® 3 F/7 Q. <br /> `('" G4 43301 <br /> Cify State IP Code Time In Time Out <br /> Business Rep Title O AM OAM <br /> ! m'MOPM m'm O PM <br /> J —= OperatlonaLStatus The Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) / �j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r. ° Active Passenger ®Generator 0 Outdoor <br /> GPS Latitude 0 Q Closed Q Altered I Q Hauler Q Indoor <br /> -�-1 O Q Inactive Q Truck <br /> Longitude - I 11 171 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 <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 a Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 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 /> Q Q PRG§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 txT) <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 /> 101 Q 1 Other: § <br /> Commentsw. IVC_ <br /> _ 4.���'r �N,SP=t��-�T-'7e--.���E.0--L.1/r_J"C C,/A/'*✓ Gi�—/�e /L <br /> _�_�f_S_� c%2_w Fai:.�Jg,s� �� N.au[,••��—teDT .4p_p_Rc%D__�vkMFcsr_� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> iuslyass Rep's Signature Phone Number Inspectors Signature Phone Number <br /> (� <br /> INSTRUCTIONS ON B CK Correct:• Incorrect:X(% ��(wJ E X A M P L E 1 2 3 62081 <br /> ■ - While Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />