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08087pG0035 <br /> Waste Tire Survey & Inspection Report -inspection ReportNumber- ■ <br /> rr Cfto of WMB1dllternla Survey Form - Page 1 1 7 - 1 0 7 9 4 6 0 <br /> gwM6 187 stew nage y g <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR.BLACK INK PEN. <br /> Business Profile- inspection Details <br /> TPID- Inspection 5, 3 � � � Q I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local . c- � If Referral,choose referral type(Fill one) <br /> Identifier: G71, ^�"oejL V'. CgK'_'� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> IS c h„r, at203 I f <br /> City State Zjp Code Time In Time Out <br /> Q AM <br /> m Q AM®PM ED <br /> m ®PM <br /> Business Rep Title <br /> Operational Status Tire Type .. Business Role Storage Type <br /> Tire Count(Whole/PTE); I i i (Fill one only). (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger .0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive ®Truck <br /> Longitude _ �I�O 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business.Type (Fill all that appy) /V <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer. 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®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 /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 . 14 CCR§18459.-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 ® —.--- ----- - --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 10 Other: § <br /> Comments <br /> It <br /> Inspection Form Included:Q 3,660 <br /> Comments Included:0 — SOGZ'? 66 23 <br /> Business Rep's Signature Phone Number'• Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ( I E X .A Afr P L � ' 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />