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!. <br /> ' }" 092100S014.9 <br /> =it il e_ Waste Tire Survey & Inspection Report . Inspection Report Number <br /> �� State of California <br /> Cgrated asteManage Survey Form - Page 1 � 1 - 1 9 — 1 0 7 9 3 5 5 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � O t - � Inspection Type (Fill one) <br /> Site Suffix: 11 e� Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: Sc{� Jl�l �(, �� Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � �,Oes br0 ,��Adwns �� <br /> 1 L-6nuac�a-_-, <br /> St er eis_ _ <br /> �k0 cA� g5a1 � Inspection.Date <br /> Time In Time Out�����JJ I—J <br /> City State ZIP Code <br /> Business Rep Title AM0 AM <br /> 1r• I PM ® ' 1 O (b PM <br /> Operational Status Tire Type Business Role Storage Type <br /> j C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE)'` I , I <br /> ' 3.�'� ®Active Q Passenger IS Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS <br /> Latitude <br /> GPS , L <br /> —I—II Q Hauler Q Indoor <br /> —I —LTJ O Q Inactive ®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 Is 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 <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility EN O C MEM S TUS <br /> V A A LING A D MAN FES REQUIREMENTS Q Notice Of Violatio Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O 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 <br /> Q O 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 t xT) <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 C-IWMB Enforcement <br /> Q O 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 Q 1 Other. § <br /> Comments \ t <br /> c� to ine.. ( cel-tu - cmc". <br /> 1M <br /> Inspection Form Included: Q . <br /> Comments Included: i♦ - - <br /> usiness ep's S' nat a Phone Number Inspect 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: 1 orrect: X R hA P 'L 1 :Z 3 <br /> White Copy. Yellow Copy.Operator Pink Copy.LEA <br />