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�73�4©4t�0�6 <br /> ja <br /> Waste Tire Survey & Inspection Report Inspection Report NumberSesta°f a"'°rn,a <br /> CIWMB 181(Naw 04104( Survey Form - Page 1 ' ( 8 - 10 7 3 4 9 7 <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I ; Inspection Type (Fill one) <br /> Sita suffix: l j 3 L�l� —�J I��� •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �- S44A -TQ'w4un J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 IT_ Inspected By Inspector <br /> � v_r_W vc�,l— St�aN'n°lf — — p <br /> Physical Address , L3 / �_ -�_ <br /> - Inspection Date [_)Tj1- / � � / [�r7] <br /> —mac in_ _ cA <br /> - - Sir:ia ZIP Coda Time In_ _ Time Out <br /> Business Rep Title 1 o AM F -r� 0 AM <br /> [7] <br /> _—J <br /> L-L-Jopm I--�._ PM <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 /> ' r •Active Passenger &Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> _...._1,D Q Inactive Truck <br /> Longitude - i i Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •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 ENFORCE'M-'E'fNT•-STAT_US___.____ <br /> V 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m /.m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 1 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 /> Q Q Other: § A <br /> Comments ' 4.N <br /> —� �IA�YrYt.tl t� oin`4 ,— <br /> } <br /> Inspection Form Included:0 <br /> Comments Included:Q ^ "a ( o +// ^-- <br /> Bu ss Rep's Sign ure Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK I Cor t:0 Incorrect:X(1� q E X a P E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />