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40 <br /> 093 gnsoov <br /> =e; Waste Tire Survey & Inspection Report Inspection Report umber <br /> State CIWMB Califoew 9 N. <br /> I 1 - . 11413 2 3 <br /> California Integrated'Was81 tJe Ma agement Board S041U) urvey Form - Page 1 . 1 <br /> Part A-Survey �_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- =8 � <br /> Q lInspection Type (Fill one) <br /> Site Suffix:, �5J l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: �In_��E ��� �-�l/r t v/� Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name 1 Inspected L_OBy Inspector <br /> Physical Address <br /> 13_I__oLL ,, t� A m e_ <br /> s3`fao_---� _,ger__F_�%_ h,`�S I I . <br /> Inspection Date <br /> S-- - -C Time InTime Out <br /> C:Ity S'taie � CodB --_ ---. <br /> Business Rep Title U�z 1 ID1 ��O AM I r 1 �; 1 O AM <br /> � ' 1�� ®PM <br /> Operational Status Tire Type- Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o f ' f ­',�ctive Q Passenger ®Generator'• ®Outdoor <br /> Latitude r - —I O do Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> Q Inactive . Q Truck <br /> I i <br /> Q Planned ®OTR <br /> Longitude - r' I �I � �O Q End-Use Q Container <br /> g <br /> Business Type .(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • p.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 L!bey1,Cty �bmmml/ <br /> Part B--Inspection of Waste Tire Dealer,.Generator, Hauler-and End-Use Facility. ENFORCEMENTSTATUS <br /> V A HAULING AND MAN IFESTREQUIREMENTS .. wr « _ ,� <br /> _._. .,_._.. --.--O• -�- H->- ..-• Q-NotI6FOf'Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �` At'iI4 ",s, <br /> t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C mpliancelodAdline ` <br /> Q Q PRC§42956-Registration/Decal in Vehicle � f '"" <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements rDate / / <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB % t VA. <br /> Q 0 <br /> Uwe 11 for NOV or t7ff) 3. <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 dayss c <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q fReferredyl CIWMB_Enforcemenl at1-1;P <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesL <br /> a <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsfComplianceNoViolatioris <br /> 0 Other: <br /> Comments <br /> ��r�'JmPi�'Ji <br /> Inspection Form Included: Q <br /> ' fib0t6.7 <br /> Comments Included: - — — 164 <br /> -- <br /> sin ss�ep's S' atu Phone Number ol' gnature Phone Number <br /> INSTRUCTIONS.ONBACK C ect� Ioect X AA P L E1 11.125 620811 <br /> s " <br /> White C py:C Yellow Copy:Operator Pink Copy:LEA <br />