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Waste Tire Sl. . trey & Inspection Repot , Inspection Report Number ■ <br /> State of California <br /> CrtdeBagSurvey Form - Page 1 ! I a - 1 0 7 9 1 3 2 ' <br /> California Integgratedted M <br /> Waste Management Board <br /> Part A - SurveyBLUE OR BLACK INK PEN <br /> IBusiness Profile ! Inspection Details - <br /> TPID - - - _ - Inspection Type (Fill one) <br /> } <br /> Site Suffix: I i ! q 1 <br /> 1 � 1 � I I � i 7 yl t' I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral, choose referral type (Fill one) <br /> Identifier: �Z> . Ckn TO ^' q to1r GC) _tr, Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> �- '\, I ' � <br /> 'Physical Address - I Q ) <br /> I �. f l :- filen Inrnc I <br /> I Mcarl �. R � <br /> Strear — ! <br /> Inspection Date <br /> II ' <br /> State ZIP Code Time In Time Out <br /> Business Rep Title - - -_- - -- -----.-_.._ <br /> Q AM 0 AM <br /> Qref calk nf. '_ Q PM 0 PM <br /> - — 1:7 rO AL <br /> -- - - - -- - Operational Status i Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) e (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> " --- ® Inactive Q Truck <br /> LongitudeN <br /> – Q Planned Q OTR /A 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 0 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - - <br /> QNance Of Violation Q Extension <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 /> PRC § 42956 - Registration/Decal in Vehicle <br /> Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date <br /> m / m / m <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 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 / CIWMB 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 <br /> in Compliance - No Violations <br /> Q Q Other: § ' <br /> Comments <br /> N� eros. . .="1'af¢ �k-tai- ) t�. �nC-� 1t1 ., • � �� c � \.-�-, hc.� f-_ �`', ` _ <br /> —T J <br /> v <br /> Inspection Form Included: Q <br /> Comments Included : - <- II - '-LL - - / //1J,�.CiLr�a=-- �+�-- 14 <br /> - Business Rep's Signature Phone Number _ - InspeEt6r's Signature Phone Number <br /> IN ON BACK <br /> Kite Co c wM• incorrect: <br /> XP7/ ,mss j A :', = 1 C F C ' 3 1 62081 <br /> ■ Operator Pink Copy: LEA ® ■ <br />