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=ire Waste Tire Survey & Inspection Report <br />State of CaliforniaCFWS <br />04/04) <br />CalifomlaInt q M d,81 WasteeMa aaementBoard Survey Form - Page 1 <br />892SS040SSS <br />Inspection Report Number ■ . <br />I'll - 1127608 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPISite - <br />Site Suffix:! <br />IFzi - <br />Inspection Type (Fill one) <br />Q0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP . Q CIWMB Q Complaint Q. Educational Visit Q Other <br />Local <br />Identifier: _ �yi� <br />Business or Facility Name V <br />L fec��C�'L° _ j'lf` I <br />Ph site Address <br />Inspected B <br />P Y Inspector <br />D <br />l 1� 1� <br />Street <br />Inspection DateO� I-�-, <br />-, <br />City State ZIP Code <br />Business Rep Title0 <br />Time In - Time Out _ <br />AM <br />I' 0 AM�PM I I ®PM <br />_(, <br />Operational Status Tire -Type Business Role Storage Type <br />The Count (Whole/PTE) <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />• <br />® Active Q Passenger ® Generator Q' Outdoor <br />Q Closed Q Altered <br />Q Hauler ® Indoor <br />{ 0 <br />Latitude <br />GPS <br />—�T--- 10 <br />Longitude I <br />f I I •I � I <br />Q Inactive ® Truck <br />Q Planned Q 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 Q Other I I <br />Part•B.—Inspection of -Waste Tire Dealer, Generator, Hauler and End=Use Facility ENEd '.EMENTSTATUS'" <br />ai1G -� t t 7 w� :. <br />Y, A HAUL ING AND�MANIFESTREQUIREMENTS' ; �f�•�.#� <br />"`'` Ha Q;Notice;Of Ylolations 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. <br />Compliance Deadline, f; <br />Q Q PRC § 42956 - Registration/Decal in Vehicle �M4 .","77 <br />. <br />O Q 14 CCR § 18459 -Responsible Entities Complying with Manifesting RequirementsDatel�ME-14ft, <br />O O 14 CCR § 18459.1 -Tire Program ID Number from CIWMB m <br />O O 14 CCR §18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days-. (Rerred foANOUor„E7C1)yy <br />cow <br />Q O 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years' gyw+ `�4pp+{�{r$ <br />.�. V'RY,@,y 5..�dfS1i Y••('S `�'RWt �Q Y• .yywi �•�.B�.R!f( <br />Q O 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers Q, Referred / CIWMB aEnforcement <br />O O 14 CCR §18461 - Manifest System Re uirements.for Waste Tire End -Use Facilities � .':"� �s•a.�:.....n -. ? team; <br />O O 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />�, In ComplianceNWiolatioris- <br />O O Other: <br />Comments <br />—.i�,.�S��k Q <br />iY� <br />S_x_20 c <br />A-10 L/ .S o��iac�rr-r <br />Inspection Form :nnc:luded: Q <br />Comments cuded: Q <br />7Cq/ <br />o WT !b 73 <br />LBusi ess Rep's SSI ratur� Phone Number In ct is Sig ure _ Phone Number. <br />a.' 62081 . <br />INSTRUCTIONS ON BACK C erect Incorrect `•�t',�f�` E X R��A P L E 1 2 3 <br />White Cop : CI Yellow Copy: Operator Pink Copy LEA ® ■ <br />