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09259040013 <br /> € Waste Tire Survey & Inspection. Report Inspection Report Number <br /> a,e I1 1088State of Callfomla <br /> California <br /> oifornia Integrated Waste Management Board Survey Form:- Page 1 453 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ' 1 Inspection Type (Fill one) <br /> Site Suffix: I 5� $ I - J ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalU ` l If Referral,choose referral type(Fill one) <br /> Identifier: J JOW�(�f� ��(}�t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i l <br /> L-IC o rho-5 CC- `Io w� - 1 3 91 _ 'I <br /> Physical Address <br /> Street <br /> c� Inspection Date I qua _ <br /> Cit" <br /> �� State LIP Code <br /> Time In Time Out <br /> Business Rep Title O AM F �� - i� l�AM <br /> 4PM !♦ PM <br /> - -•—.--- Operational Status TireType Business Role Storage Type <br /> The Count(Whole/PTE) . O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that-apply) <br /> -6 Active ®Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fieet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 ENFORG-EMENT STATUS <br /> V <br /> M11100 MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O 1 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 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 (Requi fo NOV• FXn <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 Referred!CIWMB nforcement <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 Co pliance - o Violations <br /> Q Q1 Other: § <br /> Comments �— � t� <br /> o f C'-,o -CAM <br /> Inspection Form Included: Q24 <br /> Comments Included: zno <br /> siness Re, I re - Phone Number Inspe, ors, gnature Phone Number <br /> INSTRUCTIONS N BACK •orre ncorrect E X a A� P L E 1 '2 3 62081 <br /> White c.:5 <br /> o y.CI B Yellow Copy.Operator Pink Copy LEA <br />