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072620 50002 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rn= Clate of WMB11(Noa Survey Form - Page 1 1 1 7 10 13 2 6 2� <br /> CIWMB 181(Now <br /> nage �/ i <br /> CalHomia Integrated waste Management Board 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details _ <br /> TPID D - O t Inspection Type (Fill one) <br /> Site Suffix: 111 •/III `h/ iJ 1 o Routine Q Re-inspection Q Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��Q —� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> pn Business or Facility Name Inspected By Inspector <br /> Physical Address F/Tou <br /> I 5t0ClLfirrn C9- <br /> Street �-y <br /> /�!wo 7r�� Inspection Date <br /> City /�l(1 GY �"� late IP Codc Time In ,P Time Out <br /> Business Rep �( u L p p/� :MOPM F-D 0O AM O AM <br /> WAS Of V ^ tVtiV` � V wr � <br /> _- PM <br /> -W Operational Status Tire Type Business Role Storage Type <br /> I© (Fill a only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> t ' dive Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> Inactive ®Truck <br /> Longitude - Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ WA-- <br /> 0 New Tire Dealer Q Auto Repair Is 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 Q Other (, <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT_STATUS <br /> V I 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 /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m /Fp <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 EXT) <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 U Referred 1 CIWMB Enforcement <br /> Q Q 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 Compliance - No Violations <br /> Q Q Other. §L — <br /> Comments <br /> f�cusi�'evus ori sit He fa " roe -fit h+s soh <br /> � , lt��►►'t_t��-h `���e S s �1'Ve. .S�nL�'�-�YttG�l1✓5 AUC'✓ <br /> Inspection Form Included:Q �1: <br /> comments Included:® `,} 4)J3 �'� �Businessgep's Signature e Number ! tor's SI n tura Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACKFc • Xorrect: Incorrect: E X A M P L E I Z 3 <br /> ■ White Copy CIW KM Yellow Copy.Operator Pink Copy:LEA ® ■ <br />