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09210040501 <br /> Waste Tire Survey & Inspection Report Inspection Report Number. <br /> „ Stateof 81(N niacrWew - 1108434 <br /> California Integrafd d,Waste Management Board Survey Form - Page 1 <br /> Il Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> --ice ' <br /> TPID- /�f--� Inspection Type (Fill one) <br /> Site Suffix: I L I I Routine Q Re-inspection Q Referral Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Say JO �,ti Il CoU,c,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or aciiity Name <br /> Inspected By Inspector <br /> Physical Address 3 1� l <br /> Street <br /> I ��O` 1 �� r �` Inspection Date <br /> EoI <br /> �, / A/l\'•G�1 State �Z,p Co.,3 TimeIn AM Time Out _1 <br /> Business Rep Title F I I I T I� PM I � ��� ; � � i � PM <br /> �� <br /> Lou�S --- --- — <br /> -I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' + ®Active Q Passenger 40 Generator Q Outdoor <br /> O <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler 4h Indoor <br /> 'O Q Inactive ® Truck <br /> Longitude — ,' Q Planned Q OTR o End-Use Q Container <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 <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 ENFORC-EMENT STATUS <br /> q 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 o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q o 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q o 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 o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § — <br /> Comments-- , x <br /> 9. V r,.oQ�t -- --/l—n-- i---- ------p---' ' '•�� n (� ,,'1 <br /> z4 <br /> 44 A <br /> Inspection Form :nc <br /> ncluded: Q C/ <br /> Comments luded: Zc�9 329-7b I <br /> e Rep'stature Phone Number Inspec resSign.ture Phone Number <br /> 62081 <br /> INSTRUCTIONS Co <br /> ON BACK MOORE correct: E X M P L E 1112 3 <br /> White Copy CIW Yellow Copy.Operator Pink Copy:LEA <br />