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08248040023 <br /> PWH Waste Tire Survey & Inspection Report Tln1spection108818,q <br /> RepQortQ1NuQmbQer ■ <br /> ■ WHO <br /> State of California 1 1 1 O V V 1 V V <br /> CIW tediwa Ne Manage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I / Fol <br /> 3 13 13 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6I4/JJOS,✓ C'pvAJ� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address l ©I I �� <br /> -' <br /> Street � <br /> , / ,/ Inspection Date <br /> IIV�AN <br /> �%/7 <br /> 953 <br /> City State Zi 3 -Code� Time In Time Out <br /> Business Rep Title �� I , O AM j I O AM <br /> _ I • <br /> - _ _ - --- --- <br /> - ' _----� O PM -- -- �_-_ <br /> _-Jp <br /> PMTae- -Ca�_,beA OperationalStatus Tire Type Business <br /> Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> 0 Inactive Q Truck <br /> Longitude - ,! Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 0 Other �r � T/1•N/� �Sa/e��'w� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 111 / FI-11 FI-11 <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 EXE <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 Q Other: § <br /> Comments <br /> X10_%:[G wbt2PL .A.0 71 <br /> ' <br /> _� •��a>� ja&4 G _ 16o_e, 3g 1-0 ems.• _,4v_� <br /> Inspection Form Included: Q �y"oe <br /> Comments Included: — —- f <br /> Business Rep's tune Phone Number Inspector's Signature Phone Number <br /> ---_ _ <br /> INSTRUCTIONS ON BACK orrect: Incorrect: E XAIMt P L 12 3 62081 <br /> ■ White opy CI M Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I — <br />