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., 0��-x._6090487 <br /> Waste Tire Su 'y & Inspection Repor Inspection Report Number <br /> H10H3:- State of California iClWT c_ <br /> cal fomia Integrated M tWas Waste81 Managementagement Board Survey Form - Page 1 11 1108499 <br /> Part A- Survey BLUE.OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � - �� Inspection Type (Fill one) <br /> Site Suffix: 1,5 <br /> O Lo III llt���JJJ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCOv ,� QCHP QCIWMB QComplaint QEducational Visit <br /> Q Other <br /> Business or Facility Name ((( Inspected B <br /> P Y Inspector <br /> Physics Address <br /> Street <br /> �v�-yy K''�7}'y� , Inspection Date <br /> o_�"-`--`"- -I ��- �� � Time In _ Time Out ___ <br /> City Sate ZIP Coce <br /> Business Rep Title — I , I 0 AM I , 0 AM <br /> ,�. 3 )t <br /> �� �� PM � � ' ,� ;C7 � ®PM <br /> - — Operational Status Tire Type Business Role Storage Type <br /> The COUnt(WholelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active Q Passenger ® Generator ® Outdoor <br /> Latitude O Q Closed Q Altered <br /> ('7P5 Q Hauler Q Indoor <br /> _-'.O Q Inactive ®Truck <br /> Longitude <br /> Q Planned Q OTR Q End Use Q Container <br /> I <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 �• ,�y�� ,�_(o <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> 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 (Required for NOV or EXT) <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/C-IWMB 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 1 Q 1 Other: § <br /> Comments <br /> r <br /> -Y <br /> Inspection Form Incl ed: C` <br /> Comments I cluded: Q <br /> Busine P's sid Phone Number lnsp66t#s Si a e Phone Number <br /> INSTRUCTION CK Co rest: I correct: O X A M P L E1 11 [21-3 62081 <br /> White Co y:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />