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x. 01 95050021 <br /> go 1:::Waste Tire Su&y & Inspection Repo Inspection Report Number <br /> " . CW of California I 1 - 1143686 <br /> Cgrated Waste <br /> Survey Form. - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 11 3 l Q , ® Routine ' 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: J �(` � 0 CHP 0 CIWMB '0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _ Inspected By Inspector. <br /> 7 <br /> _c-anseoMU ,o(\ <br /> Physical Address V <br /> Street <br /> � CA <br /> R5:= Inspection Date� <br /> City State ZIP Code F <br /> TIn Time Out <br /> Business ReP Title f 3I 0 AM 0 AM <br /> 0 PM 1 S O I PM <br /> Operational Status Tire Type Business Role Storage Type <br /> S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> Tire Count(Whole/PTE).'' <br /> 0 Active 0 Passenger 0@ Generator 10 Outdoor <br /> - - i i 0 0 Closed 0 Altered <br /> GPS Latitude i I 0 Hauler 0 Indoor <br /> �� � ��--�---`—IT-7 0 0 Inactive 0 Truck <br /> Longitude - i i I I 0 End-Use 0 Container <br /> .l I 0 Planned • OTR <br /> Business Type .(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair S Trucking Fleet 0 Government 0 Retreader. 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility .-, , <br /> ENFORCEMENTSTATUS'�„ '. . <br /> s•y A HAOQ@N AND':_MANIFEST R111 U EMENTS .� <br /> 0 Noti&bf Violation •�;0 Extension;K0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. I R. ``" � <br /> 0 0 § 9 �Complialice Deadline •�•� -.� <br /> 0 0 PRC§42956-Registration/Decal in Vehicle , *�r <br /> - <br /> 0 O <br /> 14 CCR§18459- -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orDCT)- <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O '•>• <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste.Tire End-Use Facilities xa • mF �« e r+�� , <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In4Compi ance No;Violations <br /> 0 0 Other: <br /> Comments �. la_+ <br /> ��`0�in� �- <br /> Inspection Form Included: 0 <br /> Comments Included: _ re <br /> Business Rep's Signature Phone.Number Insp r s Signatuone Number. <br /> 62081 <br /> INSTRUCTIONS ON B7WhitetClWMB; <br /> reIncorrect ,t, {� EIX AIM P L E . 11.1213 <br /> Yellow Copy.Operator Pink Copy.LEA <br />