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t�9i.�2 ���230 <br /> Waste Tire Su. by & Inspection Report Inspection-Report Number <br /> neatt� State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 X11 - 110 8 418 <br /> California Integrated Waste Management Board —_--____-___ _ <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> e (Fill one) <br /> TPID i - - -_I I —' -- _ i Inspection Typ <br /> Site Suffix: <br /> Lail ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i I If Referral,choose referral type(Fill one) <br /> Identifier: �5�� j�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busi6ci <br /> ess or Facility Name Inspected By Inspector <br /> y �'Y1P��(I � Z� - <br /> Ph A dress LV I� <br /> _ mb� <br /> S,raL? <br /> Inspection Date 0 L/ i <br /> _a5tgl01 � l� ---( <br /> Time In Time Out <br /> Business Rep Title ] -O Q- ® AM — > — -'—�/ ®AM <br /> U 0 PM � ` � / O PM <br /> 5- - fxo 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 /> t f ® Active ® Passenger ® Generator # Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _ 0 Q Inactive & Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility JENEOMEMENT STATUS <br /> MIMIHAULfNG AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violatio <br /> Q Qn Q Extension <br /> 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 Date <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 EX7J <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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments ��-L���-- , - - � _.L,� ��-p Q✓-)��L��� Q yf[-1___L/'L�. <br /> Inspection Form Included: Q <br /> Comments Included: Q ff [ct <br /> Business Rep's Signature Phone Number Inspe or' Sign u Phone Number <br /> INSTRUCTIONS ON BACK C rest Incorrect: E X A P :L E . 11121:3 62081 . <br /> Whi Copy:C Yellow Copy Operator Pink Copy LEA <br />