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092100.40235. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State Bof CaliforniaClWO18104104) <br /> CaliforniaInegMed WaseeManagement Board Surveyform - Page 1FI � SVL <br /> 88 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: Eil3Za� 3 _1 1 _ I_I J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / CHP CIWMB Complaint Educational Visit l/_Ar1 -OcJ`�1 Q Q Q Q Q Other <br /> L�ayl <br /> Business or Facility Name U / Inspected By Inspector <br /> L_ n fdd 1 nG. I _ <br /> Physical Address � � � L , ,� d� <br /> _tV -7YJ.. I 'I Iv�j.�t� - <br /> Street yr <br /> Inspection Date <br /> C Time In Time Out <br /> tty � State 7_1P Coae <br /> Business Rep Title m 0 AM —� � Q AM <br /> M l V � I® PM ®PM <br /> - -- --- - — — ---- J 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 /> ID Active Q Passenger .® Generator IS Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -- -- - -- -- Q Inactive 0 Truck <br /> Longitude - ' ,i Q Planned Q OTR Q End-Use Q Container <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 l I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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!C-IWMB 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 /> e <br /> CiAou, a C'� <br /> o_�oI J-)DOOJ or <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep' a Phone Number Inspe Si at Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect Incorrect: E X A m' P L 1 'Z 3 <br /> . White py:CIW Yellow Copy:Operator Pink Copy LEA <br />