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��iR104C2Q5 <br /> = ro_ Waste Tire Survey & Inspection Report Inspection Report Number_ <br /> E <br /> State of California I 1 - 1108411 <br /> CrWMB grated Waste <br /> eManag) 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- I Inspection Type (Fill one) <br /> Site Suffix: O i ) <br /> I —_� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: I— �� Jo,Ct VV �%o - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 01� <br /> Physical Address � � � � �— �`(.iv�►vV <br /> _J <br /> L61 -1 <br /> Street <br /> _ Inspec-tion Date—�- <br /> _rCa I _ I_J-1 —! D <br /> pCi, Sfaiz, Z1.- Time In- Time Out <br /> Business Re -- <br /> J <br /> Title O AM O AM <br /> -R0L.�} _O� - i 1 Pi1q ® PM <br /> V I jar ��,W Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) . (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 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 Q Auto Repair I* 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 ENFORCEMENT STATUS <br /> V A HAULING ANB MANIFEST REQUIREMENTS <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 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/GIWMB 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 Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments _ 1�S �s eS / f u[- <br /> - ►'7 <br /> inspection Form �nc <br /> ncluded: Q Q9 L <br /> Comments luded: Q C'' 2rc) , �a <br /> ;Rep's Signature Phone Number Inspector's Sig re Phone Number <br /> INSTRUCTIONS ON BACK Co reef: ncorrect: E X A M P L E 1 2 3 62081 <br /> White Cop :CIW Yellow Copy.Operator Pink Copy.LEA <br />