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09210040498 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B California I 1 110 8 4 8 9_ l - <br /> Cgrated ,tteMaagei Survey Form - Page 1 - 1 <br /> California Integrated Waste Management Board I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� L-0 <br /> Inspection Type (Fill one) <br /> Site Suffix• � is I 5 JI _ ' e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C _- J I-YA G� 4T Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Jc:.vx'rCe:s)sn- 63)3&1 /� I <br /> 5XI ! V 111 —-nn -- ( � <br /> M.G.fI.�.C.1SG� �� I <br /> Street <br /> Inspection Date <br /> Z tWe� Z!?Coaee Time In Time Out <br /> Business Rep Title I - - - ®AM —I i^ i d AM <br /> O PM / l�, ® PM <br /> PL kcz r - -- <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 /> Active Q Passenger is Generator 0 Outdoor- <br /> Latitude <br /> - -- O Q Closed Q Altered <br /> GPs -__ 1 . I - - Q Hauler ®Indoor <br /> _ -- —r---- -- --.-- --- _. -.__.,O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORGEME-NT STATUS <br /> VWAM&WAULING AND MANIFEST REQUIREMENTS <br /> iolation <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of VQ Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-omplianc Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 for NOV or EX77 <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 I CIWMB E forcement <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 10 Other: § <br /> Comments __CW_75%i � <br /> Inspection Form Included: q <br /> Comments Included: - L, _ `�� <br /> *B, nK;0�ep's Sigrjkture Phone Number Inspe f es Sig at a Phone Number <br /> INSTRUCTIONS ON BACK orr t ncorrect: IEX A P L E 1 '2 3 62081 <br /> White Cop CIW Yellow Copy.Operator Pink Copy.LEA <br />