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49259040648 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> a;'i, eCWMBNw 04104, I 1 - 10 8 6 9 8 0 <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- 3101 <br /> O Q � [�Z_ <br /> Inspection Type (Fill one) <br /> Site Suffix: / 7 ,, II ((�� I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /jam If Referral,choose referral type(Fill one) <br /> Identifier: 1 � "- - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> / <br /> Physical Address i ✓ 1 � � i � I L� I�,(u ` - � <br /> MA(,t -k9t <br /> I 04 75,) <br /> 1 Q I Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleAMW FQ <br /> ®AM. <br /> O PM I _ Co <br /> 0 PM <br /> l� Mp-c _ : 17q _ <br /> Operational Status Tire Type Business Role Storage Type <br /> ' <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f ®Active % Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -_r O Q Inactive ®Truck <br /> Longitude - Q End-Use ®Container <br /> g I . ; Q Planned Q OTR <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 ENFORCEMENT STATUS , t <br /> V A HAULING ANQ.MANIFEST REQUIREMENTSf � <br /> " " ""' Violation �Q Extension r <br /> Q Q 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 <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/CiWMB 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 ,a f >licLn i ld _+_�L&* <br /> rro c� .�� ✓ <br /> �It 4�)_ <br /> Inspection Form Included: Q 474-4D( <br /> Comments Included: Q — T <br /> B sin s ReWs Si ature Phone Number Inspector's ' nature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect� Incorrect: Mh X A P L ; 1 2 3 62081 <br /> ■ White Copy CIW Yellow Copy:Operator Pink Copy:LEA <br />