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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> IIi state of California - — <br /> Cgrated 1(teManage) Survey Form Page 1 I 1 108692 <br /> California Integrated Waste Management Board <br /> Part A- Surve ' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( I / I �) � - [6k] <br /> Inspection Type (Fill one) <br /> Site <br /> Site Suffix: `"� ` <br /> 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local VQy) ' Co \ _ / If Referral,choose referral type(Fill one) <br /> Identifier: y l (.� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ess _� ' 3 � - 1 0 1 t�^,__ <br /> Physical Addr _ L_� lU/F- &rzt.bul I <br /> Street F176 <br /> 6 Inspection Date <br /> (SfVGM <br /> Citi State IYO de Time In Time Out <br /> Business Rep Title 0 AM AM <br /> J I O PM ` J ? I O PM <br /> 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 /> f ®Active QPassenger � Generator <br /> ®Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude ;• Q Hauler Q Indoor <br /> _O Q Inactive Q Truck <br /> 1Longitude i ` ! QEnd-Use Container <br /> OTR <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 O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> I <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 1 Q 1 Other: § <br /> Comments <br /> v C r <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> 8 i ss Rep's Sig Phone Number In tots i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orre Incorrect: X (�V_ X A -M P EJ 111213 <br /> ■ White C py:.Cl Yellow Copy.Operator Pink Copy:LEA <br />