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rim Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ltzli- <br /> L& CI MB 81California <br /> (New 04104) Survey Form Page 1 1 1 0 7 9 "3 6 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- <br /> b Inspection Type (Fill one) <br /> Site Suffix3 V ( , Routine Q Re-inspection Q Referral - Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: �QL) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I G.eS SC-�t,JG�b-- I _ h <br /> Physical Address 1 (21 <br /> Street © � Q 5 <br /> �y�, 4tt5Inspection Date <br /> City- �C� ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> EE 0 PM � ' © © ®PM <br /> J Operational Status Tire Type Business Role" Storage Type <br /> Tire Count(Whole/PTE) !; i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Passenger ® Generator Q Outdoor <br /> O <br /> Latitude �I .I Q Closed Q Altered <br /> GPS J-1- <br /> I - OQ Inactive Truck <br /> I* Hauler Q indoor. <br /> Longitude " <br /> Q End-Use Container <br /> - I -- 1_. �----J Q Planned I* OTR. <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notit:e Of Violation Q Extension <br /> 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 <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 = <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 1 Q 1 Other: § <br /> Comments �0��, cam„�.,, ��� �Q..K.�Q►1�1��_ ��� 1-� <br /> Inspection Form Included: g��, r 99� <br /> Comments Included: C�— 7 <br /> Business Rep's ignatur Phone Number In or's S re Phone Number <br /> INSTRUCTIONS ON BACK Co rest. ncorrect: E X A P L I 3 62081 <br /> White Copy.CIWM Yellow Copy:Operator Pink Copy.LEA <br />