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0'416104R0-23 <br /> = : Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof181(Now <br /> ;LI1 - 1088447 <br /> Californialntg MdWaseManagementBoard Survey Form - Page 1 I <br /> tart A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i + Inspection Type (Fill one) <br /> Site Suffix: 411 Routine Q Re-inspection Q Referral Q Observation <br /> Locale . <br /> � —� If Referral,choose referral type(Fill one) <br /> Identifier: a ! J 'i n &Ur Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LJ-(C Mo� J,_A <br /> Physical Address I I Irnt <br /> Inspection Date <br /> t v I ' <br /> , oa-- Time In Time Out <br /> Cit �t�:.. LIF Codi <br /> Business Rep Title --� —T AM AM <br /> i <br /> is PM OPM <br /> l•L1 Cei Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active ® Passenger 0 Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer •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 /> VA HAULING AND MANIFEST ENjTjSllllllllllllll <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q .14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> QQ 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 F <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/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 Other: § p l <br /> Comments R,�, ��,0_R_���Q' �� �5 At �'�`-�^ 1- - 011 1——1�r <br /> J— <br /> Loon <br /> t�c'e •. `- �c�cs�,,� l�,Se-S_�L�Q,c�S`��(1�i C Ce��Sr�eSQ r�V�c�S�e-'�i�-—I�-�U��� <br /> Inspection Form Included: Q <br /> Comments Included: Q — - ���+ -F F <br /> Business ep's Signature Phone Number Inspe rs Signature Phone Number <br /> INSTRUCTIONS ON BACK JE X A M P L E1 111213 <br /> 1 2I3 62081 <br /> White C py CIW Yellow Copy:Operator Pink Copy LEA <br />