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092SSOSG087 <br /> orr: <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 I 1 - 1127635 �- <br /> CryVMB 181(New Y <br /> California Integrated Waste Management Board — <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> -�—. -- --T — r-- <br /> TPID- I I / O I Inspection Type (Fill one) <br /> Site Suffix: __.! I a ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I — • If Referral,choose referral type(Fill one) . <br /> Identifier: j Sy V C - C t!/�J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name u <br /> 'Inspected By Inspector <br /> -"�` e -- - --- 5--- - <br /> Physical Address �� - --��i ! - I / I 0j <br /> -C-4 -- -q5-';v <br /> Inspection Date -O I -2� <br /> C tr 00 -%?_^r.e ' Time in Time Out <br /> Business R•epQ A Title /—JJ l I ,�-- i - - ®AM i - -I - j I .� I F�AM <br /> ( V I _�0 PM / II D_j QPM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 <br /> t f o Active Passenger Generator <br /> _ ® ® 9 0 Q Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude <br /> GPS ; •i Q Hauler Q Indoor <br /> --_-__O Q-inactive Q Truck <br /> Longitude - I 1 j Q Planned Q OTR Q End-Use ®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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Y A! HAULING:ANb,�MANIFE$T'_kE_C QIREMENTS ' "�� -,�k ' `' t•�• €•� <br /> t Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires x <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date EE": <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB r .a -. f - �• x <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requ/rekiforNOV oriX>7 <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:/CFWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements focWaste Tire End-Use Facilities a �. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a " y <br /> ® C <br /> Ina ompliance NoViolations: <br /> Q Q. Other: .§ T• <br /> Comments <br /> ht (�-—W_RSe—7`l✓_'e_S cZs R 2_ <br /> U . <br /> e—fir fe. 4+u/er d LTL _n t Y� s arm <br /> Qrder• Taws _ ' � fo o Thor 19 1 <br /> h 9s <br /> Inspection Form Included: Q <br /> Comments Included: QIva --� <br /> ness RepsSignature Phone Number Inspect4ri Signature Phone Number <br /> , M.� � R x EqX MPL E 2 3 62081 <br /> 'INSTRUCTIONS ON BACK C rr' I <br /> lect ncorrect � �- <br /> White Cop 'CIW Yellow Copy.Operator Pink Copy.LEA <br />