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092590SOOSO <br /> Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> State of Calitornla. I 1, 1086905 <br /> Cgrated asteMana a Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI°- It 5 y 1 Inspection Type (Fill one) <br /> Site Suffix: 1 Is Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> yo\-1 oY1— <br /> icCorr_�.� 11 2� i <br /> Physal Address ` I v [ 0 1 LAI-- (_4-- <br /> (can_& J <br /> Street ff <br /> Inspection Date 6 a 3 <br /> City Stam ZIP Code Time In Time Out <br /> Business Rep Title 10 AM l I I I O AM <br /> �\,� �l D ( ' l o_' O_j o PM ` ;�' !C) ®PM <br /> j+f 1 r.` _ C. FC) -- --- Operational Status tus Tire Type Business Role Storage Type <br /> �, O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; <br /> I&Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HA LING AND MANIFEST REQUIREMENTS ® Notice 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date a 3 <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 DCT) <br /> 0 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 Referred/GIWMB nforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR.§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In C•o pl ance - No Violations <br /> 0 Q Other: §�19,- - -- — -—S. <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Usines Rep's Signature Phone Number In' e4torls,$196ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co eet: Ineorre¢t: E X A 114 P :L E <br /> ■ White Cop :CI Yellow Copy.Operator Pink Dopy:LFJ1 <br />