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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> IN—181 INew 041041 <br /> califomla lntegrated Waste Management Board Survey Form - Page 1 11 1088391 <br /> Part A-Sur-Vey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( - D ' Inspection Type (Fill one) <br /> Site Suffix: 0( I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �j a _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T /fes o"`` °. <br /> PhyL sical Addss csLV- <br /> cJ i <br /> Street T /�+� <br /> I 1__ �Tf g�3(' I Inspection Date <br /> City State ZIP Code Time In "/�f�j v Time OutV <br /> Business Rep Title MO ` �xu� O (�J AM - OI I I Q AM <br /> PM <br /> Jh <br /> -tM_en___ �- - Prational Status Tire Type Business Role Storage Type <br /> . t - (F.ill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f t ` 1 O <br /> ®Active #Passenger Q Generator Q Outdoor <br /> GPS Latitude 'o Q Closed (8 Altered <br /> ®Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ I ' ' i i i Q Planned ®OTR Q End-Use ®Container <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 /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer i Collection Q Crumb Rubber 7� <br /> Q Service Station O Hauler Q Agriculture Q Shredder 0 Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT ST TUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Notice . 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. Couto lance Deadli e <br /> PRC§42956-Registration/Decal in Vehicle �] <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements O Qf <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB c7 <br /> 0 O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX!) <br /> Q O <br /> 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/CIWMB Enforcemen <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 •t Co pia ce N Viola i n <br /> Q 1 Q 1 Other: § <br /> a 1 <br /> Comments�w,,.-}�,_� �y�� ✓� �/ _ „l_fV�l7� � _- — • //KS <br /> i S ✓2 �r�fits1 1 J { r (��_ UI!` cuus-twp ✓'S (7vc_� <br /> �s °� �pasa,2 sv-���csz. Trichv1� C�►s+Y --- -��� <br /> a$_K 8 _� v►_u, ' _ 'T a hi Ai was fe re- <br /> 5 <br /> Inspection Form Included: x3�{ �(�f�� <br /> Comments Included:®' 83� o6or — -- <br /> Bu I esa Rep's Signature Phone Number Inspecto s Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: In •rre t: E X' R P L E 3 62081 1 2 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />