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092.59040670 <br /> Waste Tire Suroy & Inspection Report Inspection Report Number <br /> state of California I 1 — 114117 4 <br /> CIWMB grated ,s(New eManage Survey Form - Page 1 <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Q Q Inspection Type (Fill one) <br /> Site Suffix: L—"� � - <br /> t. ; Routine Re-inspection ' Referral Q Observation <br /> LocalI / r- 1 If Referral,choose referral type(Fill one) <br /> Identifier: L Sad \ J o W,'\ CUu - _ ' CHP 0'ClWM13 ' Complaint ' Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L LIAIDA- <br /> Physical Address <br /> r <br /> Street � � <br /> C rr (i� Inspection Date ��-1LOI IL <br /> Cits' S �� 1 � Time In VVV / Time Out <br /> State ZIP Coca _ <br /> Business Rep = Title O AM T,) r <br /> ® AM <br /> � OPMOPM <br /> _—J L_ <br /> �}- - -- - Operational Status Tire Type Business Role. Storage Type <br /> The Count (Whole/PTE) . - (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ' Passenger 0 Generator ® Outdoor <br /> 1 ' Closed ' Altered <br /> GPS Latitude -� I Q Hauler Q Indoor <br /> T_ —r J D Q Inactive ® Truck <br /> Longitude - j . I I I I i 1 Q Planned 'OTR Q End-Use ' Container, <br /> Business Type (Fill all that apply). <br /> ' New Tire Dealer ' Auto Repair ' Trucking Fleet ' Government ' Retreader ' Dismantler 'Tire Derived Fuel <br /> ' Used Tire Dealer ' Auto Body ' Car Dealer ' Collection ' Crumb Rubber <br /> ' Service Station ' Hauler 'Agriculture ' Shredder •Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility :ENFORCEMENT STATUS " <br /> VHAULING AND MANIFEST REQUIREMENTS <br /> ' Notice,Of.Violation 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 Date. <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m" m ` .•m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> Q ' 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years z , <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Refetied'/=C_ IWMB �Enforcement � <br /> ,r - <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 A In Co+mphance No Violations, <br /> Q Q Other: § <br /> Comments <br /> T 1 t <br /> Inspection Form Included: ' <br /> Comments Included: ' --A <br /> -��Business <br /> Ign ure Phone Number Inspere Phone irribir <br /> INSTRUCTIONS ON BACK 'C rrec`t: VA 'ncorrect- " fr NX A�M P � E 1 2 <br /> C y: 3 62081 <br /> f <br /> White C y:CIW Yellow Copy:Operator Pink Copy:LEA <br />