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•iu. <br /> Waste Tire Survey & Inspection Report - Inspection Report Number <br /> -;_ $hMof E31111lomla Survey Form - Page 1 1 8 - 10135414J <br /> CIWMB 1a1(Naa OHet) <br /> califomle I "lad Waste Ma--- <br /> Part <br /> ane-- 9uaM <br /> PartA-Surve BLUE K INK PEN <br /> Business Profile Inspection Details 62 -i O C(0(14 <br /> sitesE �t Inspection Type (Elle one) JV se <br /> Site Suffer: d � 4 � 1 ®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 Name Inspected By Inspector <br /> Physical Address <br /> L6C,>7 <br /> Street b Q d <br /> 1Inspection Dale <br /> ga ,t�10.Eie ZIY C' Time In Time Out <br /> Business Rep Title 0 AM0 AM <br /> FTI:Erlop. 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> U Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) <br /> ®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 L ) <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS O 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 D.I.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 FX7) - <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 Reforrod 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 0 Other: <br /> Comments <br /> / • <br /> 4!k <br /> Inspection <br /> Inspection Form Incl7ded <br /> Comments Incl - �- -7-�- — a <br /> Bull s Rep's tore _ Phone Number ctor s Ig re Phone Number <br /> (� �� E A M P L E 1 2 3 szoal <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ® . <br /> While Copy.CIWMB Yellow Copy.OGerelor Pink Cony LLA <br />