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G �2 �. 00404�9 <br /> EBo. Waste Tire Survey & Inspection Report Inspection Report Number- <br /> State <br /> umber- <br /> CIWMB 81(New 04104) Survey Form - Page 1 I 1 - 110 8 4 8 7 <br /> California Integrated Waste Management Board Y g _ <br /> __] <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �J ` I I Inspection Type (Fill one) <br /> Site Suffix: O j lJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: "`�n ^,,, ? \ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Is—Fcil LA_ —� _ <br /> x_155 E , <br /> Street <br /> Inspection Date <br /> City Stat.- QIP Co(,.- Time In Time Out <br /> Business Rep Title ! J l --7- Q AM — — Q AM <br /> ep <br /> ')CXr_ �- fel- -- -1- --- - �- - -�- e►' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V FA I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 0 Other § <br /> Comments QYff. <br /> �Cc�—YLQ�� <br /> Inspection Form Included: i <br /> Comments Included: Q / I <br /> Business Rep's Signature Phone Number In a is ig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS NS ON BACK Correct: ncorrect: j ( E X 1d►0 P I L I <br /> White Copy CIW Yellow Copy:Operator Pink Copy:LEA <br />