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osi2so4it� � <br /> Irr <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr 6tateelxelNonle Survey Form - Page 1 I 5 - 1 0 7 2 8 2 7 <br /> CIWMB lrt Itierr rtaga - Y <br /> Calilomla Inbpraletl Waw Manapemeltt eoertl <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� Inspection Type (Fill one) <br /> Site Suffix: I 3 ✓ 18 18 T14 - O I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalJ-0 <br /> — If Referral,choose referral type(Fill one) <br /> Identifier: 6(10— J©ct n C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Lll__ Inspected By Inspector <br /> J <br /> I Qer�U I <br /> Physical Address I / I <br /> 5_1 1P0,-� P pa I �1 <br /> Street Inspection Date <br /> 95atta� <br /> City � Mate ZIP ode rime In Time Out <br /> Business Rep Title O AM O AM <br /> m <br /> MOPM 0 PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r I *Active ®Passenger ®Generator ®Outdoor <br /> i <br /> GPS Latitude OI O Closed Q Aftered Q Q <br /> Hauler Indoor <br /> O Q Inactive ®Truck <br /> Lor ltude - F ] FI I__T. Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair a Trucking Fleet Q Government Q Relreader 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 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Rel nSw_c*en A, S �// <br /> uyas <br /> aver-� q �1 5�rzmo�� a Ct QI i ►'peoS. ✓iUt fC`67t-S 410h44 <br /> Inspection Form Included: Q <br /> Comments Included:Q �— — 943-7�7r "--� <br /> Business Rep's Signature Phone Number Inspecto' Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:�( 62081 <br /> ExaMpLE 1 ;23 <br /> ■ While Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />