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09196040472 <br /> Waste Tire. SuSby & Inspection RepoIrtm <br /> ereye:i1State of 181(Ne la 9 <br /> Cgrated Waste <br /> eManag) Survey.Form - Page 1 <br /> California Integrated Waste Management Boats <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 Q 3 3 6 Q I le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Qn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Nil _ 1 0 1 L�� � _(1QJ <br /> Street <br /> Inspection Date <br /> L�'Sk `0> l Time In T [ <br /> City 7t tae ZIP Coae Time Out <br /> Business RepTitle O PM G 0 O PM <br /> AM 0 AM <br /> �jvCG O l o � ((( 66l <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> I `, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ;y <br /> ® Active Q Passenger ® Generator ®Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS _ i • Q Hauler Q Indoor <br /> JO Q Inactive le Truck <br /> Longitude - -j j I I Q Planned ® OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) 1 1 <br /> Q New Tire Dealer Q Auto Repair Q 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 Is Other L_6C -1 nit <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V = 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 I 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 C-ompliance - No Violations <br /> Q Q1 Other: § Q \ _ i1 r <br /> Comments �\Q� �l-SQ�C C�0✓�C Pry! �k-S. all"r� <br /> l� 1/1 bl G ,� C� �S OF'C INJ�r'✓b <br /> Inspection Form Included: Q - `� 6 -Q673 <br /> Comments Included: Q - 6 <br /> QIS)�LB iness gnature Phone Number I ctor' S nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKC r'�c : Incor�ct� X M L E 1 ,2 3 <br /> White C y. Yellow Copy:Operator Pink Copy:LEA <br />