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092SS040622 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWCalifornia Integra^ted Waste ManB.i81( ow naagement Board .Survey Form - Page 1 I 1 1127611 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O l(1 L/ D l Inspection Type (Fill one) <br /> Site Suffix: L ( Routine Q Re-inspection Q Referral Q Observation <br /> Local u,,l CVS/1V If Referral,choose refers (Fill one) <br /> Identifier: �-�j{,� � UU � 0 C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Ph is tires I 7 <br /> ' I Pik AA ff <br /> nC� Inspection Date i q� <br /> Street a n � qt b ! ---- i / 1 I / ` <br /> City Srate ZIP Code Time In Time Out <br /> Business ReTitlep <br /> - �1, <br /> —/—I �— O AM <br /> o O AM <br /> OLILa � Amr0perational <br /> 'Lv ® PM PM& J <br /> •Status <br /> 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)' 14 <br /> f ' #Active ®Passenger ® Generator Q Outdoor <br /> i i <br /> i O Q Closed. Q Altered. <br /> Latitude <br /> GPS j I i Q Hauler. Q Indoor <br /> — -- -- 1 — --1 Q Inactive Q Truck <br /> Longitude i li Q End-Use Container <br /> Planned Q OTR <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 ®Car Dealer QCollection 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 /> HAUCING.AND MANIFEST-REQUIREMENTS <br /> ,Vr xAs',., .-- - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 M / m / m <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 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 /> Other. <br /> Commentsh/� ` -f k'c' A 4 <br /> i`C_ o <br /> wlc�we�Qsf- fity V i w ec tl� <br /> No viol 0-hVIA S nz)f.ej <br /> Inspecti Form Included: Q ' <br /> Comments Included: Q —� U 6 ;Sionaiur, �"�Busi ss Rep's Sig atur Phone umber Inspe Phone Number <br /> ,�� I 62081 <br /> INSTRUCTIONS ON BACK Corr ct: correct: E X R MIP L Z 3 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />