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■ == Inspection Report Number <br /> M Waste Tire Survey & Inspection Report <br /> ur_ <br /> slilei"°`�' Survey Form - Page 1 �3 6 - 1 01 31 21 <br /> cnYMa tet(Nan ouoy <br /> caf"ornia Integrated Waata Memganwnt Board BLUE OR CK INK E'EN <br /> Part A-SurveY _ — -- <br /> Business Profile _ Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: I /^7 / 4 7 Q Routine ®Re-inspection Q Referral Q Observation <br /> - - - I H Referral,choose referral type(Fill one) <br /> de tlfler: � CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1`• `-✓ inspected By Inspector <br /> rte: <br /> Ph sicalA�dddress <br /> Street Inspection Date � V <br /> State -7!p Code Time In Time Out _ <br /> Business Rep Title I AM <br /> mpPM i OP- M <br /> operational StatusTire Type Business Role Storage Type <br /> (Fit <br /> i l one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t , <br /> ®Active ®Passenger I®Generator ®Outdoor <br /> — _ O !1 Q Closed Q Altered <br /> GPS Latitude ! ®Hauler Q Indoor <br /> Q Inactive Q Truck f <br /> Longitude - - Q Planned -I Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> t Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q ReUeader Q Oisman8er Q Tire Derived Fuel <br /> I <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ! <br /> Service Station Q Hauler Q Agriculture Q Shredder Q OtherQ <br /> - <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> y 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 I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or DCT) <br /> Q Q <br /> 14 CCR§18459.2.1-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 I CIWMB Enforcement <br /> Q Q '1 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities - <br /> IQ Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance • No Violations <br /> LQ Q Other: § <br /> Comments '�1�E7�O�i �Joir�`' v+9 _ _ �ci��iL �Atn► _ (. �- _(' ia.l+ - <br /> ---�-t..�kf wag__y_w-t-' __y.-sl-{'�• - I=[�+"�- h�.f^- Gtlz,r'�a6�¢_. _ <br /> (tyv v-ew!e- .R _ <br /> Inspection Form Included- <br /> Comments <br /> — ? <br /> �� f� n <br /> Comments Included:®I- v -fr1=� <br /> usiness Rep's Signature Phone Number In or s SiSt Phone Number <br /> - • 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: E A thh P L E 1 2 3 ® . <br /> White Copy.CIWMO Yellow copy;Operator Pink Copy:LEA <br />