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0, 28.0840114 <br /> .H. Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> clwMe 181 04104) <br /> California Integrated Waa ea Management Board Survey Form - Page 1 I 1 - 112764):] <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- E, Inspection Type (Fill one). <br /> l r— <br /> ol -I� .� FE il - <br /> 0L <br /> Site Suffix: <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:- _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or.Facility Name V Inspected B <br /> P Y Inspector <br /> I TQUCir•� TMJ <br /> Physical Address -- <br /> vz -- <br /> Street �� �q --- Inspection Date ! <br /> j— i! <br /> City -�` 5 ate Zip Codq Time In Time Out <br /> Business Rep Title - ; - — - - AM ik�j <br /> �- --� i —� Q AM <br /> rr l �e Yr►�fZ2 1 <br /> -D1 � ' -1 - ®P i 'I ✓ iJJ1 ® PM <br /> M <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 /> i7 ®Active ® Passenger Q Generator' Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I j ..� - L-� --� i Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ' j ' i .I I End-Use Container <br /> I I I I Q Planned OTR Q <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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility_ ENFORCEMENT�STATUS" : ,.. <br /> 'V A HAUUNG'AND MANIFEST.REQUIREMENTS`_. .. # j <br /> Notice Of�Violatlon Q�Extension, _ <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires +� � ' r ..r. <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complfan Deadline, m �r <br /> Q Q PRC§42956-Registration/Decal in Vehicle f <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date �/:mN_ <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 10. + r <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days- (- (equired for NOV or EXTJ <br /> Q O 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. QReferred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilitiesh <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f <br /> Q Q <br /> In Compliance,= No Violations.„ <br /> Other: § Yet G ' s <br /> -,�i <br /> Comments - cv, -� - -11 ches c t „ — ^ 11- s <br /> lnaS _jL v i`1 G�M S {-�T L(1 QSfT[�� CCS t' SCl�sl(/t�tb <br /> A -rtY �sIeSp !`n 200`7 No I ;s�o s � la • <br /> t4ks a lUo Jto ,�6t <br /> Inspection Form Included: Q (� <br /> Comments Included:Q — - - - - _ <br /> Busi ass Rep' i na e. one Number Inspector' ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C r."ect: Incorrect: &779r EXAMPLE 1112 3 <br /> White Copy: IW Yellow Copy.Operator Pink Copy.LEA ® ■ <br />