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ill <br /> Wast <br /> e Tire Su�y & Inspection Repo nspetaion Report NumberState of California i 1 0 4 7 5 2 <br /> Cl WMB181(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- {� Inspection Type (Fill one) <br /> Site Suffix: � —f L+ 2 - [� <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �— If Referral,choose referral type(Fill one) <br /> Identifier: -�, - v, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address C:50 j - t y <br /> 1 4-73-7 C - <br /> Street <br /> Inspection Date <br /> I � <br /> 52./ I Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title 0AM O AM <br /> mm� PM m0P <br /> Operational Status�T�i e ype Business Role Soorrage Type <br /> The Count(Whole/PT (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed ;Q Altered <br /> Latitude � I j { Hauler Indoor <br /> GPS Q Inactive �Q Truck j Q <br /> Longitude - Q Planned OTR Q End-Use <br /> , alm6t app <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date m / m / m <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 EXT) <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/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 1 Q Other: § <br /> Comments <br /> spection Forrn Included' <br /> y ? <br /> Comments Included. -- -- - -------- <br /> - - ----- ---- �' - s - = t� <br /> Q Business Rep's Signature Phone Number InWector s Signature_ Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E )f, A M F 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />