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080�g040184 <br /> ■ 'en Waste Tire'Survey & Inspection Report Inspection Report NumberState .� <br /> CFWM,3Calltornla Survey Form - Pa e 1 19 - 10 1 3 5 9 7 <br /> CBryMB 101(New Ml04) n <br /> Callfomia Integrated Waste Management 9oard � `..` <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J' L Inspection Type (Fill one) <br /> Site Suffix: [T <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Named Inspected By Inspector <br /> Physical Address FLA—. _j <br /> Street Inspection Date <br /> I Mtw►kcc�. � 95_33 LJ I Z O 4 O <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m <br /> MOPPM m is PM <br /> - _ - <br /> Operational.Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 i { I <br /> ®Active Q Passenger '®Generator Q Outdoor <br /> �I O Q Closed Q Altered <br /> GPS Latitude W, - Q Hauler Q Indoor <br /> I� Q Inactive ®Truck <br /> Longitude Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 1111 <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 ®Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VM HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice tN Violation Q Extension <br /> Q Q PRC§42953 Contracts with Registered Waste Tire Haulers. Co pliance Ueadtine <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 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/or NOV or EXE <br /> Q 014 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/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 1 Q 1 Other: § <br /> Comments <br /> �.a,.�_•u.. tYltpst�Za>~.��_1�����, '�&tt�N.i'-l,cn�lL�J�,w�;_s `r <br /> krc� s. S"►on r 1r ,� t.c sli +,� t� •—Notes } J <br /> Inspection Form.Included:Q / <br /> Comments Included:Q ^ c'�! �Qbt/Jtts� `/� c,.�1 — <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correet: Incorrect: X A M P L E1112131 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />