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® ... Inspection Re-p_ort Number Su y & Inspection Repor —I <br /> ■ <br /> - <br /> � 5"£a <br /> State of California <br /> C181e <br /> I 1 - 1088085 <br /> California Integrated Waste <br /> Management Board Survey Form Pg1 _ <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey — <br /> Business Profile Inspection Details <br /> TPID- 1 1 Ins ection Type Fill one <br /> Site Suffix: 1 AJI Routine Re-inspection <br /> Referral Observation <br /> �.. <br /> Local If Referral,choose referral type(Fill one) <br /> a _ '7� <br /> Identifier: C)lt <br /> �� �(} `��,lt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector ' <br /> �, �� <br /> Physical_l Address L'_; I L,___— � <br /> street <br /> ( r.I N. <br /> sos Inspection Date <br /> —1Time In Time Out <br /> City state ZIP oce _—..... — 0 AM AM <br /> Business Rep Title j PM IJ-�] ' O <br /> 10 PM <br /> ( 1 1u til f Operational Status Tire Type Business RPPStorage <br /> Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) I <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude T�= Q Hauler Q Indoor <br /> _,0 Q Inactive Q Truck <br /> Longitude - F-FT-TT <br /> j Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that arvly) <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 <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 Date <br /> Q Q14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> f- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § - - <br /> Comments CA 4 <br /> - <br /> � t <br /> _.. f <br /> , <br /> Inspection Form Included: Q <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Numbei „sped„ '..ignature Phone Nuia,hei <br /> -- — <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X 11�- 1,/ "X%r A Mj'? � I t( 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />