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Waste Tire Survey &.Inspection ReportInspectio$r�epoN.1.1be' . . <br /> c" <br /> State of SurveyForm Page 1 16 10 7 91 6 2 <br /> CIWMB 181 sNaw adage) <br /> Celifomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5i 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ay V� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d Inspected By Inspector <br /> r� <br /> Physical Address <br /> lj��9 1 / lei / 111�107� ___j <br /> I 26 ko o PIA 2A � I - - - <br /> Street Inspection Date D 3 i✓ <br /> City State ZIP Code Time In Time Out <br /> Buslness Rep Title O AM O AM <br /> !/may <br /> MOPM [1] m O PM <br /> ! _`^-,(A/!�-__NUJ C S ___ I�X!✓r.ct ��� Operational Status Tire Type Business Role Storage Type <br /> 4 � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE).� !�' � I ' Active I&Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude LL_ -I L—111 I _� 1 Q Hauler Indoor <br /> ( (� Q Inactive Q Truck <br /> Longitude – _F <br /> I i�o Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader, Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 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 Data 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 EXT) <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 , 1 <br /> u_77'�IG <br /> an- c�6 <br /> _ ✓e AZ:77 _.rte—.c/ _f_c¢,__Jo t/reIAT�'a IS f�Cs_e I <br /> Inspection Form Included:Q! (74A) <br /> i a Comments Included:Q -- 468��?3 <br /> B ness Rep Signature Phone Num Inspector's ignature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: AA E X M P I L E 1 111213 162081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />