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�: . Waste Tire Su � & Inspection Repor spection Report Number <br /> _ <br /> State <br /> caLjj4j CIWM of California Survey Form - Page 1 I - 1088114 <br /> .+,fo p CIWMB 181(New nage) ry <br /> lifornia Integrated Waste Management Board y - -. <br /> Part A- SurveyTy BLUE OR BLACK INK PEN <br /> Business ProfilegaInspecton Details <br /> TPID- I_ O - Q Inspection Type (Fill one) <br /> Site Suffix: Z I ® Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �O Q 111 Il r) u(l� <br /> _ � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physic' --.w_ I <br /> al Address <br /> _� <br /> C.oun ire _ cn er � III���... <br /> L1 OU -S _S ac.raM!ex o St• - J — <br /> street �Q 71 / D 5J / �� 8 <br /> LQ ' G� _ Inspection Date <br /> Cii; State''-Z� ccie Time In Time Out' <br /> Business Rep Title ---` PM -- AM <br /> - 11 <br /> � � O <br /> fE O AM O PM <br /> �� 1r�sy„w,,����.IM „ �i t A Operational Status' Tire Type Business Role Storage Type <br /> Tire CountTZ P s (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor` <br /> U Q Closed Q Altered <br /> PS Latitude <br /> � Q Hauler Q indoor <br /> 1 1 <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> E �sMe 3s Type (Fill all that apply) <br /> IQ New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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 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 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/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: § - ---.I <br /> Comments R Ot I <br /> �r`e_. +n`:;nec_-t-I�n aer��rrY��f _�h►� c���fe � -�hQ. -��11�_,�*�.�.la�� nd�ecl <br /> "Fanom,- neer o, era_ ►�CkS 6SCOLA _ Tire CeY`ter , -0,,� <br /> Gtirn <br /> Qwyer k4-- t; -,- 'Jan C) new OCArrc 0 -S Cl ► otl Is D►�11caun ire <br /> 94zC-"MfkLn(A `to � nAc.- NVrNe _-TT 1D 110-71��01 <br /> Inspection Form Included: Q <br /> Comments Included. Q , fes,,. l � ,ra.,. , v► ` <br /> Business Rep's Signature Phone Number fsp6ctor s Slgnatssr ! Phone IFla,;rnlser <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />