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^: 0�3�404Qt1g0 <br /> ■ ''eec Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> StateCalitomla Survey Form - Page 1 I_ 6_-- 1 _0 7 3 4 7 0 <br /> CIVYMB1e1(New 041041 <br /> Callfomla Integrated Waste Management Board j. __ _ <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- jInspection Type (Fill one) <br /> sit.suffix: j .31 <br /> I Lj <br /> __�_-_ _.f3 1— _ LO 0 Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ---'b� , O CHP Q CIWMB 0 Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> - - ) F4T'-? F/11__oT Physical ddress �p <br /> Inspection Date <br /> UP Curio Time In Time Out-1 <br /> — - <br /> Business Rep Title Q AM T Q AM <br /> l PM I- P PM <br /> L.evnr a aL� <br /> - <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 /> ®Active ®Passenger ®Generator 0 Outdoor . <br /> o O Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder I*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 /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations <br /> O O Other: § <br /> Comments <br /> �f2i s �aa��►xcu.�.i c� 12z+ar... <br /> --- <br /> 2 rOLt141_Vn9- <br /> . <br /> Inspection Form Included:O <br /> Comments Included:Q4. 16)natuie <br /> � f Z 5°68'a y3 <br /> Busine Phone Number Inspector's Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( X A M P E Z 2 3 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />