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ere- <br /> Waste Tire Survey & Inspection Report.. Inspecti n R°p ort N�mur0 ■ <br /> rr <br /> State or191(N w Survey Form - Pa ge 1 1 5 . 10 7 9 4 5 9 <br /> CIWMB 191(New Odled) <br /> Callfomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / y 7 6 l 0 <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: u$.anns�i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 j t7 <br /> 42-1 <br /> Street <br /> Inspection Date <br /> L __ rlsw3 <br /> City rl�trrn State ZIP Code Time In Time Out <br /> 0 AM <br /> Business Rep Title m:F ®PM 0 AM EE <br /> 'm 8 PM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude --I i� JO ®Closed Q Altered <br /> 1 Q Hauler Q Indoor <br /> l Q Inactive Q Truck <br /> Longitude — I I 1 ��o Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ®Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V , A I 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-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 IX7) <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/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 1 Other: § <br /> Comments <br /> � �,-c{�c�t-e�-Le.—'�_►+ic_c(Gdt�,- �uC.�dt��lOe���- G��i:.�s�r�t� <br /> �. <br /> _G_vtcrk.—finc��o t_isr�Gytf o_n—r�_f� /_P!!�_ - —• <br /> Inspection Form Included:Q <br /> Comments Included:Q — — 7� <br /> 0(023 <br /> Bus ignature P e Number - Inspector's Signature Phone Number <br /> �, <br /> ( 62081 <br /> INSTRUCTIONS ON BACK Correct-* Incorrect:X(% 9 X A M P L E 111413 <br /> 3 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />