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f Waste Tire Su�y & Inspection Repor* Inspection Report Number <br /> N <br /> z' State of Californiappp���e CWMB <br /> 1 Waste <br /> Survey Form o page 1 1 1127583 <br /> California Integrated Waste Management Board Survey ��ii <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y� ,� FAI Inspection Type (Fill one) <br /> Site <br /> Site Suffix: �q ? <br /> LL ` t� } 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local % I If Referral,choose referral type(Fill one) <br /> Identifier: Oct L�� (� �t)�,I �(J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ! — <br /> Physical Address [YE LIJI-0�Ij <br /> €...._..._ ..._...-..a.._.......__.,k'.. -:1.._.F......_......_. ._ _!_.......K...t`_ <br /> Inspection Date_..._.... ...._tie"-.:.1...._.._.�...�!_.�...Slt„_I .:_m__....._._......u. <br /> (k <br /> Sato ZIP Code <br /> �` Time In Time Out <br /> Business Rep Title ` _ O AM r . ...i.. .. . AM <br /> O PM I I I O PM <br /> ._..__. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) iVn <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GFS Latitude r0 Hauler 0 Indoor <br /> — - — -- '- 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR� <br /> 0 End-Use 0 Container <br /> Business Tyne (Fill all that apply) ` <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NO'✓or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments .r <br /> lit, <br /> Inspection Form Included: 0 <br /> Comments Included: (Jy <br /> Pusines:Rep's wigratme Phone Number I,ispentor s Signature P.-hone;,;uwber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: o2G81 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />