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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of181(New I1 — 1088096 <br /> Cgrated Waste <br /> Management <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r� —1 Inspection Type (Fill one) <br /> Site Suffix: 5 1 G I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalC- If Referral,choose referral type(Fill one) <br /> Identifier: tib Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t <br /> Inspected By Inspector n <br /> Physical Address <br /> 1�� Srec kl�s A-v-p— -r� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep \4 <br /> _Tiittl@{� 0 AM O AM <br /> �ctY�OcV�e(� 40PM C ®PM <br /> v— — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' 0 Active 0 Passenger •Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ®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 0 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 40 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation O Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> jQ Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-RegistratiorJDecal in Vehicle <br /> Q Q 14 CCR§16459 -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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§184602-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 I&In Compliance - No Violations <br /> Q Q Other. § <br /> -- ---------- <br /> � Comments <br /> L LlS (1G�2C1 <br /> I � <br /> 1�Q J!Z2�CL�Z715 C-f- 0,1` n S G CC Y) <br /> I <br /> ------- --- <br /> Inspection Form Included:Q <br /> Z0144 <br /> Comments Included:Q� �r' <br /> Busin€ss Rep's Signature Phone Number Inspect s S nal re Phone Number <br /> INSTRUCTIONS ON BACK Corr�^,,�`._/`Incorrect:X E- X;AMIPILIE1 111213) 62081 <br /> ■ .. ..\ '-. _ Pink Copy LEA <br />