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�` , C�23 � �5Q03S <br /> L== Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee:. <br /> State of California <br /> itoa <br /> California Integrated ClWMB 181 04104) <br /> WasteOManagement Board Survey Form - Page 1 , FII 108695 5 <br /> Part A- Survey" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � I � � � 1 -51 - <br /> O �Inspection Type (Fill one) <br /> Site Suffix: Routinec Referral <br /> ® Re-inspection p Q Q Observation <br /> Local �n If Referral,choose referral type(Fill one) <br /> Identifier: \(ll� C�Y L O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected B <br /> I P y Inspector <br /> Physics <br /> aAddress - �A 1�„„C,� ����Il.,•I <br /> Street V © / 1310 <br /> / <br /> CC v 1�3 Inspection Date <br /> CCit;' State ZIP Code Time In Time Out <br /> Business Rep Title I� O FM /� : i� Q AM <br /> 1:/7L <br /> r I� I O _ ® PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) '7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� 16 Active Passenger Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> CIPS Q Hauler Indoor <br /> - O Inactive •Truck <br /> Longitude - ! ; i0 ®Q Planned OTR <br /> End-Use ® Container <br /> ® <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility MENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 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 C-ompliance - No Violations <br /> 0 O Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 7 — <br /> usine "Reps_, t re t..... Phone;Number. _ In r s Sf a re. Phone;.Number <br /> INSTRUCTIONS ON C rest- Incorrect: 62081 <br /> EXAAhPLE 1 23 <br /> White Cop :CIW Yellow Copy:Operator Pink Copy:LEA <br />