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- Report Inspection Report Number <br /> Waste Tire Survey & Inspection ■ <br /> "= State ofcallfornla Survey Form - Page 1 - 17 - 10 13 3 2 9 <br /> CIWMB 581 tNew 041041 <br /> cailfomia integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> Business Profile V0 I QU 5 Inspection Details <br /> TPID- ^-� / _ Inspection Type (Fill one) <br /> Site Suffix: l 10 -7 1 ! b Q Routine Q Re-inspection Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `~~ � ^{' �({� Q CHP ® CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name n 1� Inspected By Inspector <br /> Phys� ` J ! / G✓.Y�t-/— as- <br /> 1 <br /> Street Inspection Date ( I Z q Zl S <br /> L��w-(ltd �� �S?��J f Time Out <br /> City r State ZIP Code Time In <br /> AM <br /> Business Rep Title p 0 0AM <br /> O ! 3 0 QPM M <br /> _:[�]LJ q rr�Jt.S ��s `L Q �� ` Operational Status Tire Type Business Role Storage Type <br /> f ! 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE),. f <br /> -2 d ®Active Passenger ®Generator ®Outdoor <br /> T­ I IO Q Closed Q Altered <br /> GPS Latitude I I I ,V I I I Q Hauler ®Indoor <br /> L _�-1---ILL__— O Q Inactive Q Truck <br /> Longitude - '{ i— ,i T 0 Planned Q OTR O End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B -Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V­F A HAULING AND MANIFEST REQUIREMENTS ®Notice Of Violation ®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 MO -2_ MCO6 <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXE <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 ® Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use f=acilities <br /> ------•—••--- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in compliance - No Violations <br /> Q Q Other: § <br /> Comments �FG -w.rc,� y_, I,, - CCAS <br /> ,,r l�C 7 Tie.. +,--i�"' r.l•.'�ll,..s Al V <br /> inspection Form Included: <br /> EO SZ_Comments Included: ss Rep's 1 nature Phone Number Ins or's tirmt re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:l� incorrect:( (� A M R 1 2 3 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />