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091 �b0��02 � <br /> Inspection RepgrtNumber <br /> Waste Tire Su ?y & Inspection Repor <br /> iI State of Callfomia <br /> CIWMB 1 teManag) Survey Form - Page 1 I 1 - .11084 2 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- [M� <br /> O � lo <br /> Fq <br /> (�' - O Inspection Type (Fill one) <br /> Site Suffix: ]y` ` Routine Q Re-inspection Q Referral Q Observation <br /> Localn \ If Referral,choose referral type(Fill one) <br /> Identifier: ` Q so U1 n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 I <br /> 101 I Llan - <br /> Street 5 q Inspection Date a LI <br /> L—L cq 1_a I� J III III <br /> City State- ZIP Code Time In Time Out <br /> Business Rep Title t rn : 0 PM 0 AM <br /> PM <br /> .- -� _ Operational 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 /> O Active ® Passenger ®Generator Q Outdoor <br /> r—' I O Q Closed Q Altered <br /> PS Latitude <br /> J0 Q Inact <br /> Q Hauler Q Indoor <br /> ive �Truck <br /> Longitude I ! I f j ? Q Planned OTR Q End-Use ® Container <br /> 1 I I <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other TtvAs_!4_4�jf_M I <br /> Part B= Inspection of.Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STAYT_U`S <br /> V M HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> QQ 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Date� I 5 101i"I <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 DC7) <br /> 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 I C-IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In C-oin Ilan- <br /> 01 <br /> lanQ Q Q Other: § <br /> Comments <br /> _Lk n� = <br /> �. <br /> A-luo- ate" - i�'� 5 9 3 — c�L s Q. ��t u ;l <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone umber' <br /> INSTRUCTIONS ON BACK Cor ect: mt:orreet: X � MP !LE 1 '23 62081 <br /> E . <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />