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Waste Tire Survey & Inspection Report Inspection Report Number � <br /> ■ F:r•� C" a 181Ihaw 041-)wl er++ta Sey Form - Page 1 �_ 12 . 1 0 1 3 0 2 7 <br /> clwrae tet <br /> ealifomia h%7r,ted Waste M111ga-111—d <br /> ury <br /> Part A-Surve _ BLUE��.LIArk...'�PEN <br /> Business Profile Inspection Details <br /> 7Pi0• �7 f Inspection Type (Fill one) <br /> site suffix: ) 3 �"1311 O + Routine Q Re-inspection ®Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP Q CIWMB 4D Complaint Q Educational Visit Q Other <br /> Business or FFaacilky Name L� F Inspected By Inspector <br /> I ys PI refs �i�tCG lllIHJJJJ .._ ' [3Ecli <br /> - ! D L���1yu- <br /> Ph ical Address <br /> Street Inspection <br /> �d �SalP�3 Date <br /> cl VV <br /> city c.Gr �p tate ITime In Time Out <br /> city <br /> Business Rep Title / ®AM O AM <br /> /fir 1 a QPM E J' 0P <br /> 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(WhoielPTE) , , <br /> 1 ®Active Q Passenger ®Generator ®Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude j _- - i i <br /> Q Hauler Q Indoor <br /> --y Inactive [�OOTRck <br /> IQ Q End-use Q Container <br /> Longitude Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O 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 / <br /> Q ® 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q — <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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!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 far Tire Dealers cr Waste Tire Generators" ®In Compliance - No Violations <br /> Q O Other: <br /> Comments),)*gc&r •-11u5 dW& Ram Cbb eomp la,,► rQ Fe rra.Q • flow. <br /> N?a5 `izrtediISci +u iS 11A a9ri �_ncC,� <br /> h.wA r�s 15 _tYlIvt.Cb✓es 12a 9 iced on A rr a -ut-r- ld_ <br /> &M 'A o TI ve een bra <br /> _ 2.0 <br /> Inspection Form Included:Q nnQ1 —Q <br /> Comments Included:Q Busin s Re s SI nature Phone Nu b � Inn or's gnature. Phone Number <br /> P 9 — <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:0 Incorrect: (� ENT R hi P L 1 2 3 ® ■ <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA <br />