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092170410009 <br /> U ii= aa Waste Tire Survey& Inspection Report Inspection Report Number <br /> ii State of California ew 04/04) I 1 10 8 6 9 9 7 <br /> California Integral dWaseManagern Board Survey Form - Page 1 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L Inspection Type (Fill one) <br /> Site Suffix: EL4[ b a h ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: LSMvl Cin, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , Inspected By Inspector <br /> Street <br /> L-SS*yy� Inspection Date <br /> C"-�`" —` 6" q��ftI Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title �� ��® AM F—I � Q AM <br /> Ii I , i IJ__jOPM VIZI : !O;_91l 0,PM <br /> -- .L.�� ti - •-t✓ - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that appty) (Fill all that apply) (Fill all that apply) <br /> f � <br /> ®Active Q Passenger 0 Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _O Q Inactive Q Truck <br /> Longitude - i I i Q Planned 0 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 Q Other I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility BENFORCEMENT STATUS <br /> WIMJHAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q I 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 f 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 1 Q Other: § <br /> Comments -41 b�;' <br /> —�� �nC �✓1_. <br /> Inspection Form ncluded: Q <br /> ncuded: Q <br /> 4/� �Or <br /> Comments I - _ � % <br /> Business Rep's Signature Phone Number Insp o s Signt e Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCo rwc•. incorrect: M[EjXjAjMjPj'Lj8!.j 11 2 3 <br /> White Cop .CIW B Yellow Copy:Operator Pink Copy:LEA <br />