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0918904000S <br /> Waste Tire Survey & Inspection Report !r Inspection Report Number <br /> State B 181(New I04104) <br /> 1 1108490 _ <br /> California Integrated^ Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- F —�T--I I 1 if Inspection Type (Fill one) <br /> Site Suffix: i 3i a� IqLa I LOQ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ ` If Referral,choose referral type(Fill one) <br /> Identifier: LS_a JOIMJul n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> 1 Inspected By Inspector <br /> Physical Address <br /> i-�en_ Isco —---i <br /> LA <br /> Inspection Date I <br /> ' Time_In Time Out_ AM <br /> Business Rep TitleAM <br /> \ A4p mo vo- 11 !_ O PM I 1 ' S Q QPM <br /> n , <br /> C)e'' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) , (Fill all that apply) (Fill.all that apply) (Fill all that apply) <br /> ®Active ' Passenger Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ,' Q Hauler Q Indoor <br /> _ O Q Inactive lb 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 0 Trucking Fleet Q Government Q Relreader 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 All. <br /> FP-� - <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 Notice(�f Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 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 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 Exr) <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/CfWM6 Enforcement j <br /> 0 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 Q 1 Other: <br /> Comments <br /> - �(1+�-c1`�.�c�-cin— -o�Q--�1—--n— —�u•S—t1b - <br /> No e.: �. F�c►�,;_ U�.S - �f�,c���e`►�Ce,� e�� ��n�U.�,lelr. <br /> Inspection Form :nc <br /> ncluded: Q ' <br /> Comments luded: Q .I—QA - 31' 8_ <br /> B in s Signature Phone Number Ins pe is Signature Phone:Number <br /> 62081 <br /> INSTRUCTIONS ON BACK CoIf Irect. ncorrecta E X A P 'L 1 Z 3 <br /> White Cop CIWMB Yellow Copy.Operator Pink Copy:LEA <br />