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0928005.0002 <br /> =j Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CrVVMB 1steManage Survey Form - Page 1 I1 - - 1141200 <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: I t l �gT3 Oil <br /> Q Routine ® Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ISO, S �on 6� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected B <br /> P Y Inspector <br /> Physical Address <br /> Loc 13 - L t_ <br /> LLl1_ - <br /> StrEet i I <br /> Inspection Date <br /> City L-- -vY l-- 'tate Za Coda _ <br /> Time In Time Out <br /> Business Rep Title <br /> ir �TL- l,1l Q AM � >I Q AM <br /> L-1 I— PM L <br /> 1 • F � PM <br /> Operational StatusTire Business Role Storage Type <br /> Tire Count(Whole/PTE) : (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> I*Active O Passenger ® Generator ®Outdoor <br /> II I Il l0 Q Closed Q Altered <br /> Latitude. L�-1 • -� Q Hauler Q Indoor <br /> L � <br /> Q Inactive ®Truck <br /> LongitudeI ! . I. I 1 i Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Buslness 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 /> i <br /> Part B - Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT'$TAT+IJS . <br /> VJ •P► HAUIING)'ANDiMA1dfFES;T REQUIR-EAAEN�yTS Y a a' Q';Notice Of 1/i�ola�tion,i Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of.Tires <br /> 4 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co neeDeadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle u " <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q w' R wired for NOV or,• <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ompllanc'eYlolatlonis s. <br /> Q Q Other: § - <br /> Comments <br /> C4 rnrrl�n� P� <br /> Z�7 <br /> Inspection Form Included:.Q <br /> Comments Included: - - --- &S .�Bu lines Rep's Signature Phone Number In Phone Number <br /> — — 62081 <br /> INSTRUCTIONS ON BACK 705ec * Incorrect; E-X �rJl P (: Z 2 3 <br /> WhileIW Yellow Copy:Operator Pink Copy:LEA <br />