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� ©812905008 <br /> a Waste Tire Survey & Inspection Report inspection Report Number <br /> r-1.0-111- Survey Form - Page 1 11 - 10 7 2 8 3 1 <br /> CIWMB 1B1(Now 04104( <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- � D F,5FY1 <br /> Inspection Type(Fill one) <br /> Site Suffix: D 3 (oJ - © ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ls—o,, t <br /> J d _-- - _- Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector . <br /> L_S_ -far,, �or�- 1�sfirl <br /> Physical Address <br /> I..—aa ti I Vj <br /> Street C Inspection Date <br /> �� l � ��� 1 I <br /> ity State ZIP Code Time-in Time Out - <br /> Business Rep Y Q` Title O AM Q AM <br /> . m O PM �'m O PM <br /> --— -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) O <br /> I r ! ®Active ®Passenger .®Generator ®Outdoor <br /> I ! O Q Closed Q Altered <br /> GPS Latitude 1 I I I I Q Hauler Q Indoor <br /> ——1 —'---t — Q Inactive ®Truck <br /> T (� T-11-71-77 <br /> I�I" O <br /> Longitude - I I T I,I I II� Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that'apply) 1 111 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet S 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 L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other I �(�1rT' j t✓� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Ot 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 IT] <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/C-IWMB 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 I Comp ianee - No Violations <br /> Q 1 Q 1 Other: § <br /> CommentsAff fL Cji� `� ,/1_c �f_ nclted `U AAV` <br /> s T�&_2LILl/ r�1A `rte �r rern La.Ql�e �t1C�s `r�rSu� <br /> ,from lam+ veGz-oP . Por+ Ns-W& has had Ce-rl-h`nLJ - <br /> I_��rN_`A iI1Od l� c� _'i-�s, firms a�� <br /> Inspection Form Included:Q <br /> zPA <br /> Comments Included: <br /> Buslness Rep's Signature Phone Number Inspector' ignature Phone Number <br /> r� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M1 X R P�L E! I C 131 62061 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> tl <br />