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0918204.022.4 <br /> Waste Tire Survey & Inspection Report --Inspection Report Number <br /> State of California <br /> CgrtedW Waste <br /> Survey Form - Pagel � � 14 - 10793591 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> v (, <br /> Q Observation <br /> - <br /> Site Suffix: ® Routine Q Reinspection Q Referral <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other , <br /> Business o Facility Name t Inspected By Inspector <br /> Physical Address I L—I_1 _ I &Street <br /> �slv IJ� <br /> V Inspection Date � � M� o / mog <br /> 15 0'� <br /> city �� State ZIP Code Time In Time Out. <br /> usiness ReP Title { I� : I it PM 3 O PM I <br /> L Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /y{ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> Active Q Passenger Generator Outdoor <br /> I i i O Q Closed Q Altered <br /> I � <br /> GPS Latitude I I J• , i__I �_ Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude �-— I I � - ---- - O Q <br /> Q Planned Q OTR 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 ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / F11 / F11 <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 E)T) <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 Enforcement <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 Q1 Other: § ,�t� h� /' �1 _ <br /> Comments - �' -1 )- -f�— V,x� l!�1- - S ~ C--`'� — - -Q' �Wjny U) JAM— <br /> (A o M . <br /> �b V b 1 _ yob-S Ci S C1lr�,a s o ��(1 <br /> Inspection Form :nc <br /> nclude l ,e K <br /> Comments luded. Q — _ <br /> ss e 's Si a ure Phone Numb r Ins e is Si nature Phone Number <br /> P P 9 <br /> 62081 <br /> INSTRUCTIONS ON BACK Co recta Incorrect: ( X A M P L E ! 1 2 3 <br /> White C y.CIW Yellow Copy.Operator Pink Copy LEA <br />