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091820402.25 _ <br /> im*eea_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> I State of CalNomia <br /> CFWMB 181(Now <br /> nage Survey Form - Page 1 - 1 6 - 1 0 7 9 3 6 9 <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: D 5 5LEOL Routine Re-inspection Referral <br /> Q Q Q Observation <br /> LL <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0,1/l. �� �/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I_/1�. �>�soCa_rcl - /LolilA_QQ �or�soPhysical AddressLL, I <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In <br /> In Time Out 0 AM �J <br /> Business Rep Title 0 AM <br /> E/ 1 ® PM � • ( � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i f J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active, ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude J_- 1 •I _ I_!I_�__o Q Hauler ® Indoor <br /> __---_ ____ 0 Q Inactive �Truck <br /> Longitude Q Planned Im 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 ®Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENTS ATUS <br /> V A HAULING AND MANIFEST W5-0UIREMENTS <br /> iolation <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of VQ 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 1 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 Q1 Other: § <br /> Comments R0_12�1_l.le C-6ne, a'1 <br /> Inspection Form Included: Q Z ySb C <br /> Comments Included: 0a-56—�� <br /> Business Rep's.Aftikature Phone Number Tnso6cts Sig)jfitur Phone Number <br /> INSTRUCTIONS ON BACK7Gopycl <br /> 62081 <br /> ■ POYPI.- <br /> EXAhfiP �� 1 :2' 3 <br /> White py.Operator Pink Copy.LEA <br />