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�'� �19� 17050Q49 <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection .ReportStat <br /> Lr IICFW 8181of torula Survey Form - Page 1' I 1 - 108694q_ <br /> CIWMB 181(New Management <br /> y <br /> CaliforniatoIntegrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -� A <br /> Q � � � � _ O � Inspection Type (Fill one) <br /> Site Suffix: <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 Name V Ins ected B <br /> r{ ,� ��� ,1 ` ( P Y Inspector <br /> Physical Add s 3 I � —_ -k— J <br /> Street feet ��S- �-0.��Qlfl �`-U►� I ��U II W <br /> Inspection Date 0 0 /1 <br /> tateZIP Coca Time In Time Out <br /> Business Rep Title �� . I Q AM 1 I Q AM <br /> 0 Ile PM PM• i <br /> -6p Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -3 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> .. J Active Q Passenger 4D Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> .----0 Q Inactive 40 Truck <br /> Longitude - 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 01FA 'HAULING AND M I I.E_Sd_flljf REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Ex-7 <br /> tension <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 / [I] <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 daysRequired for NOV or EXT) <br /> O ID 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/C-IWMB 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 Q 1 Other: § <br /> /� <br /> Comments /! — r <br /> V)k A LI C,Ck IS lets 9.3 344tln '11 14RC <br /> us <br /> Inspection Form Included: Q LJV,/ Ov <br /> Comments Included: ® — — / -- \/��r►J1l <br /> B sine lure one Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: ncorrect: E. X >a M P .L E.; 1112 3 <br /> White Cop CIWM Yellow Copy:Operator Pink Copy.LEA <br />