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Waste Tire Survey & Inspection Report Inspection Rp8HNurn e <br /> StateofCafiromia Survey Form - Page 1 17 - 1 0 1 3 0 $ 4 <br /> Cg"t W(New raga) y <br /> CattroMia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection n ' Inspection Type (Fill one) <br /> Site Suffix: 1 t Q Routine ®Re-inspection Q Referral Q Observation <br /> Local C I if Referral,choose referral type(Fill one) <br /> Identifier: aCi�(.(Lh Ul t�! t� _ I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1LJ1 (f Inspected By Inspector <br /> Physical Address �— — 3TO <br /> L_� v(t t,tZ <br /> a'oil Ci��t� V J I _ - <br /> Street <br /> Inspection Date <br /> S�och tov►, CSI- 903 I d <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title �j� AM nAM <br /> D O` lY O PM V ! O O Q PM <br /> �.� J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole(PTE) <br /> n r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> g <br /> r ®Active ®Passenger 0 Generator ®Outdoor <br /> GPS latitude I I i �O Q Closed Q Altered <br /> ��� •l - I, Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude <br /> —I � o <br /> 9 Q Planned ®OTR 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 /> 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 4D Other <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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date EJ / 17 / M <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 for NOV or B(T) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsIV to Compliance No Violations <br /> Q Q Other: § <br /> Comments RZ(i+i_�WfZen - <br /> L x- 101 3p�g , Rzu4 K1tre J ,} <br /> f�ddawc�e <br /> - and �"t �tivare of r6tnnon Tire• ��mus wc�e_o_ ecP �f in __ ' n <br /> Inspection Form Included:Q I�(^�� /���/ 7 (C r70Q I_r_ <br /> Comments Included:® (CI '7'JY'.'.dC�+Y _ 1 i40 L�tDW <br /> B nese Rep's Signature Phone Number fns tor's i nature Phone Number <br /> ■ INSTRUCTIONS ON BACK CorrectAe lncorrect: lYJ trI X R M P L E 1 Z 3 62081 <br /> C! <br /> M8 Yellow Copy:Operator Pink Copy:LEA ® ■ <br />