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oo"cdiv����i <br /> Waste-Tire Survey & Inspection Report Inspection Report Number, <br /> statem181(New Survey Form - Page 1 18 - 10 7 9 3 13 <br /> CONMB IBI(New 041041 <br /> calitomle Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN' <br /> Business Profile Inspection.Details <br /> TPID- / 3 g ! O Inspection Type (Fill one) <br /> Site Suffix: O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: A�' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address bl/3/3B9/1q/�� <br /> /9i'? <br /> Street <br /> I n' „J 9��Q�I <br /> � Inspection Date <br /> City �o�� (�SLtate ZIP Code Time In Time Out <br /> Business Rep Title O AM •AM <br /> i- / O O O PM ZO] D O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I D ®Active ®Passenger ®Generator Q Outdoor <br /> I I D Q Closed Q Altered <br /> GPS Latitude I - I— I—� Q Hauler Q Indoor <br /> _ D Q inactive ®Truck <br /> Longitude - I J— I I �__I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 LLL <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 ®Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility BENFORCEMENT STATUS <br /> WMj2AIJff1ING 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 I 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 1 Other: §, <br /> Comments �+� ,yy,ie�Cv. vee'-f QLLttGJo <br /> CTL 'S �r�'r.✓aal Ln �� dr rrta�.' y. <br /> Inspection Form Included:Q <br /> �L �lii �Qf4,�r�/�f�✓7s.e�t 7��—��3-a <br /> Comments Included:Q— - - <br /> Business Rep's Signature Phone Number Inspector's Signature . Phone Number <br /> _ <br /> INSTRUCTIONS ON BACK Correct:Q Incorrect: E X A M 62081 P L 1 "2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> I <br />