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- <br /> Waste Tire Sur y & Inspection Report nspection Report Number <br /> �E-uu3. State of California jf�� Q <br /> ew 04/04) <br /> Califom>�Integrated Waste Management Board Survey Form - Page 1 1 5 - 1 y 1 3 5 9 9 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details mad"'! <br /> TPID- (` Inspection Type (Fill one) <br /> Site Suffix: I I I 3 I I1 _ E01 <br /> / Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ) If Referral,choose referral type(Fill one) <br /> Identifier- JW rl L' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name li / <br /> / Inspected By Inspector <br /> l firylyrl', a`"' Ise I I� t� I �J <br /> Physical Address �— I ., �({�( C (Z— <br /> r <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep'f Title <br /> � � 0 AM � -- - QAM <br /> Mord ryl.(Ij1Q✓ 0 P 0PM <br /> � I <br /> Operational Status ire Type Business Role Storage Type <br /> Tire Count (Whole/PTE + /l /\ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V U ® Active Q Passenger Q Generator Q Outdoor <br /> Latitude ��O O Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> I1 Q Planned Q OTR <br /> Lon rtude - � . Q End-Use Q Container <br /> g <br /> Busi ess Type (Fill-afl 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING 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 Date M / M / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § I -- <br /> Commentsk� <br /> wf(ir,c Jh51CK (ILrt n{s !Cfe . 4y, (d1 �vfr.Lvtjr ,) s fOCIdA Lf <br /> c s S0,6]e 6P(V-A v�a we , k✓ tiro-' - Vj r V/ 0-721 <br /> (,t0tI jvorie�,�. IUA) () mer QS`3cG rl(LAJ 7PI -# ` . 17 <br /> spection Form Included: Q <br /> B <br /> amu. .. <br /> Comments Included: Qusiness Rep's Signature Phone <br /> Number Inspector's Signature � Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X j r, X I A MI P 1 LI E! y 2 3I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />