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0�21Q45Oi51 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> State of California <br /> Cgrated 7(teM nage Survey Form - Page 1. 1 9 - 1 0 7 9 3 3 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection q <br /> 111 � 101R <br /> _ © � Inspection Type (Fill one) <br /> Slte Suffix: I <br /> _ 0 Routine Q Re-inspection Q Referral Q Observation . <br /> Local r"" If Referral,choose referral type(Fill one) . <br /> Identifier: K�44�(�in CJ U, g Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> L-3_ALo o.- ens I _ <br /> Physical Address I 6 1 ESAm� <br /> Street I 5AW / / m <br /> /I A Inspection Date illi (VVV) j111 (JJ—JI <br /> Ci�� o- b.Q State tide I Time in Time Out <br /> Business Rep Titlel0 AM <br /> // h/f('i►/,. ' ' �0P16 A M F1 - � QPM <br /> _J <br /> _ Operational Status-Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i . II (Fill one only) (Fill all that apply) (Fill all that apply) '(Fill all that apply) <br /> o Active ® Passenger o Generator Outdoor <br /> GPS Latitude -1111--- I <br /> , I I I( 11-10 <br /> Q Closed Q Altered Q Hauler Q Indoor <br /> JJJI O Q Inactive Q Truck <br /> Longitude - El_ 1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply)- <br /> 0 New Tire Dealer Q Auto Repair .Q Trucking Fleet Q Government Q Retreader Vb Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection p 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 ENFORCEMEN STATUS <br /> V A HAULINGAND MANIFE-ST REQUIREMENTS Q Notice Of Violati Q E•xtenslon <br /> Q 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 /> O Q 14 CCR§18459 -Responsible Entities Complying with.Manifesting Requirements Date LU <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> L I <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FX7) <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 Enforcem nt <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 Complla e N Vfol tions <br /> Q 1 Q Other: § <br /> Comments o (Jl� Q <br /> % <br /> _(�0 V_I.0`4__vs�S�LU(c�cJ�S_C��Lp(1 _ (�, 1! <br /> Cs� <br /> Inspection Form Included: Q <br /> Comments Included:* - <br /> Business Rep's lure Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Coect: Incorrpff A M p,,L n 62081 <br /> ' 23 <br /> White Copy CIW Yellow Copy:Operator Pink Copy:LEA <br />