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09210040503 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B Survey rve Form - Page' 1FI1 - 10 8 6 9 0 2 <br /> State o CaliforniaCa fHew 04104) �/ <br /> California Integrated Waste Management Board J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /_T Inspection Type (Fill one) <br /> Site Suffix: i 13. 6 3 I ! I - l <br /> ® Routine Q Re-inspection Q Referral •Q Observation <br /> Local `` If Referral,choose referral type(Fill one) <br /> Identifier: V�� S[�('ln v Q(�l L/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `��1 Inspected By Inspector <br /> enc_. 1 - t loll L�i_lrn W <br /> Street <br /> Inspection Date <br /> Ca. q%? Time In Time Out <br /> City State ZIP Cods <br /> Business Rep Title / 0 AM <br /> I0 AM <br /> -i � l ' I �/ IvJ® PM =�� <br /> ' ,�l QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f. U ®Active Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -- ----- O Q Inactive ®Truck <br /> LongitudeQ 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN OR-MEME'I STATUS <br /> V A HAULING AND MANIFEST EOUIREMENtTS Ex <br /> Of ice NotViolation <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Q io <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 days (Required fo NOV or FXT) <br /> Q O 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 I®vIIn C-ompIlance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments R fvoi�ylF _P_G <br /> l le c —tea cue T <br /> �- crit <br /> Inspection Form Included: Q <br /> Comments Included:Qt <br /> B siness Rep's t tura Pon Number Ins e o Si nature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ..... ...... IEIXIAIMIPILIEI 1112 3 <br /> White Coj Yellow Copy.Operator Pink Copy.LEA <br />