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r <br /> 01312040404 <br /> ■ " e Waste Tire .Survey &,Inspection.Report Inspection Report NumberState ■ <br /> CIWMBf 18111omia Survey Form --.Page 1 i 4 - 1 01 0 6 7 <br /> CIwMa 187(New nage <br /> California Integrated Waste Management Board . <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> l Tits - F3 O O 3 r - ® Inspection Type (Fill one) <br /> Site Suffix: TLf J a Routine Q Reinspection Q Referral Q Observation <br /> Local If Referral,choose0CIW ferrel type(Fill one) ' <br /> Identifier: ///I f Y ln� _-__ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J (/.". <br /> c Inspected By Inspector <br /> �Wi 14 iL S ?iwt<� J 17 q - � 4 1 L�•e�,wt Eat <br /> Physical Address <br /> N 77 Tj I� e LeW)'s v% , <br /> Street Inspection Date <br /> I S ��h ) <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m'm O PM m'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/P E) (Fill one only) (Fill all that apply) (Fill all that apply) ly) <br /> I&Active Q Passenger ®Generato a Outdoor <br /> 4. O Q Closed Q Altered — I <br /> GPS Latitude . Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer' Q Auto Repair e 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 f I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> &VA WASHAULING 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 FJCTJ <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 Q Referred I 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 /> 1010 Other: <br /> Comments <br /> ''�'` <br /> ne <br /> Inspection Form Included:Q <br /> Comments Included:Q 1/ 4-Sn -Business Rep's Signature Phone Number I p toe Phone Number <br /> 16 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: FETXIAIMIP .. 10 111'2131 <br /> I ■ White Copy:CIWMB Yellow Copy:Operator - Pink Copy.LEA ® ■ <br /> I <br />