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092.800410788 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> L; If <br /> aoe State of California I 1 — 10 8 8 4 5 2 <br /> Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Wasle Management Board ' <br /> _�] <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /� Inspection Type (Fill one) <br /> Site Suffix: 1 3 V D 3 t J • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ a u►v` � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> Physicallqress� �— O <br /> 3 I I 1 _i L& rl <br /> Sh aef <br /> Cu C `5 M1 Inspection Date <br /> Cit <br /> y M AC State T_i�'Coda Time In__ _ Time Out y�VVV JJJ J <br /> Business Rep Title I IJOAMOAM <br /> 0 PM ! , I'� ' �lJi- � � 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 ° Q Active ® Passenger IS Generator ® Outdoor <br /> O S Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q 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 O 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 11111ENEOROEIIT STATUS <br /> HAULINGI�AND MANIFEST REQUIREMENTpS <br /> V s,�- <br /> Q Notice Of Violation Q 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 <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 0 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 n ,� <br /> U i <br /> Inspection Form Included: Q Q <br /> Comments Included: Q — ,� 6� 17 <br /> Business Rep's i nature Phone Number Insp rt. Signature Phone Number <br /> ;2 62081 <br /> INSTRUCTIONS ON BACK oc <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />