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ete_ <br /> Waste Tire Survey& Inspection Report . Inspection Report Number <br /> rr State of California <br /> C rate 1111 Waste <br /> nage Survey Form - Page 1 1 8 - 1 0 7 3 3 0 8 <br /> California Integrated Weste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspections Details <br /> TPID- (� / Inspection Type (Fill one) <br /> Site Suffix:. 413 3 / 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local /Y� If Referral,choose referral type(Fill one) <br /> Identifier. L�a�7--OArw[� / 4H/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name/��,r��7_� ��l/t/"` I Inspected By Inspector <br /> Physical Address ,,�y� _ <br /> 1,,)1,;2 pe-Ma <br /> Street �51 ' 'h / f„ i5,;)-6 Inspection Date <br /> yrttate <br /> ZIP Code Time In - Time Out <br /> Business Rep Title O AM O AM <br /> m O PM m' O PM <br /> ���jh . ken - - ,t D ice._ mvt <br /> Operational Status Tire Type Business Role Storage Type <br /> h <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' � V <br /> I Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GpS I I I Q Hauler Q Indoor <br /> ®Inactive Q Truck <br /> O <br /> Longitude Q Planned Q OTR Q End-Use Q 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 /> 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 /> y AA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 �! —(�v�t�1 �S rJ <br /> I � n <br /> `-VLIC�( or rewo 4-h`e• fo ivtQl !`I/CGCQ <br /> Inspection Form Included:Q <br /> Comments Included:Q—— C>.C��—� � — <br /> Business p's Signature Phone Number 1 e tor's g to Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(� Yj 110*1 A M P L E ! Z 3 <br /> ■ 0 7 2 8 4 0 4 0 2 7 5 While Copy CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />