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08066040052 <br /> jMWaste Tire Survey &:Inspection Report.. Inspection Report Number. <br /> C=8of 181(N.la SurVe Form - Page 1 17 - 10 10 8 4 6 <br /> C,WMB,e,thaw nag y 9 <br /> Callfomla Inlagntad Waate Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / / D / Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation { <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> r� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C V --- —--- ---- <br /> /� Inspected By Inspector <br /> Phys cal A ress 3 LA=A -'Y�f 1 <br /> Street yy� <br /> Inspection Date <br /> city State ZIP Code Time In lS� Time Out <br /> Business Rep Title O AM OAM <br /> LQ p" ' L m m O PM m m O PM <br /> Operational Status. Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I <br /> ®Active •Passenger •Generator ®Outdoor <br /> O Q Closed Q Altered <br /> i <br /> Latitude m GP$ <br /> O Q Inactive Q Truck Q Hauler. Q Indoor <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> ®New Tire Dealer Q Auto Repair p Trucking Fleet Q Government p Retreader p Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A U I G AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2:1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required(or NOV or EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire.Trip Logs for 3 years <br /> Q Q 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 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 TireDealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1"440-fly <br /> '! _�/ <br /> ,�'�> ' �' Gni L 's a�'.c�✓� 4� �'���*�'_ � .-;v���- <br /> _ o , <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business p's Slgnatur hon umber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C•or eet Incorrect: E X A M P L E• 11t2131 62061 <br /> . White Copy.CIWMB Yellow Copy.Operator Pink Copy.LFA S <br />