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07312040455 <br /> Waste Tire Survey & Inspection Report .. inspection Report-Number <br /> a <br /> CIWMB W8111M1"19 Survey Form - Page 1 13 - 10 7 3 5 2 6 <br /> CelHomla Integrate0 Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 O 3 a 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � <br /> Physical Addd ✓ � � O <br /> Street <br /> Inspection DateCA <br /> City fj S!to3-Z P Code Time In Time Out <br /> Business Rep Title *AM AM <br /> m0PM m'm 0 P <br /> erational Status Tire Type' Business Role Storage Type. <br /> (Fill one only) (Fill all that apply) (Fill all that apply). (Fill all that apply)' <br /> Tire Count(Whole/PTE) <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I I I.�- I—� Q Hauler Q Indoor <br /> LE <br /> LLL��_JJJ T 0 Q Inactive Q Truck <br /> Longitude - I—�,L. I ��11���111_t]_ 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 . I*Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of-Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT 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 /> 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 O -- _....-..------ --- <br /> 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 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 /> 010 Other: § <br /> Comments <br /> ------------------ <br /> --�n'�'�v-`'—��f�--�[-5L4=,-_�l�i s 1LL_t:kvLeQ La f.Ya'tp w:sl• ���/�i�t c S-—� <br /> _--Q'ld.�YJ��fi.G�- ,py� �7.1-4f��ICGi�iLa��4j��/✓D✓t O�_4.�7�fln s <br /> Inspection Form Included:Q y l W° <br /> / -66 <br /> Comments Ino included:Q — <br /> Business Re s-Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correc :Sncorrect: X aI P L �: 1 2 3 <br /> ■ White py Cl By Yellow Copy.Operator Pink Copy LEA ® ■ <br />