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r�nen: Waste Tire Survey & Inspection Report Inspection Report Number <br /> ��n' State of California <br /> LE <br /> California Integrated t Was eoMa agement Board Survey Form - Page 1 I 1 .108693 9 <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Lrj� <br /> Inspection Type (Fill one) <br /> Site Suffix: 5 3 10 1 ® Q p Q QObservation <br /> ��--��-- Routine Re-ins ection Referral <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 JOa r\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physi <br /> P_calcrAddressc 13 9 _ <br /> � ' loll L& <br /> L X33 ws�o�S qu�_ I <br /> Street 17— <br /> Inspection Date <br /> i S�b6A6� C �5 b3� <br /> City St'7t3 ZIP Code Time In Time Out <br /> Business Rep Titlei t ' 1 O AAM 1 0 AM <br /> 10 <br /> mc.,urlc�le -- - - PI_��1r►, - er� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f 0 Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered �V <br /> GPS Latitude Q Hauler Q Indoor A <br /> _ T--- O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) tAA <br /> 0-New Tire Dealer Q Auto Repair Q 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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other L1�'an cLA_k_�,te.r , <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEME_N_T STATUS f . <br /> HAULING AND MANIFEST REQUIREMENTS 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 t� <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 7 U �/ <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIW MB 1 <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 Q In Compliance - No Violations <br /> Q Q 1 Other: § __ <br /> Comments I <br /> All? <br /> Inspection Form Included: Q Q <br /> Comments Included: ® � `�- �S�D��7 �(Q ���^�179 <br /> Business Rep's Signajure Phone Number Insp tor's Signature ✓ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co ct Incorrect: X A Ah P L E. Y 2 3 <br /> Whit Copy: I B Yellow Copy:Operator Pink Copy:LEA <br />