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092S9040629 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number <br /> �». <br /> State of California <br /> California Integrated Waste Management Board Survey Form - Page 1 - I 1 108697 5 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 1 () ✓ � _ 7� Inspection Type (Fill one) <br /> Site Suffix: IiJ V ® Routine Q Re-inspection Q Referral Q Observation <br /> C t If Referral,choose referral type(Fill one) <br /> Identi <br /> Local <br /> fie <br /> Local r. (t{�- SbC` (,(�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `^ Inspected By Inspector <br /> Physical Address � - l Q ( ). --ek� <br /> I tK I � V <br /> y�3�I' /Upr�1�n <br /> Street p <br /> Ins ectlon Date C.() <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title0 AM , O AM <br /> j� I ' I 0,®PM I O • I O I e PM <br /> Pk/ S na q,-- ©w�- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one on (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! QP Active Q Passenger *'Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> —.0 Q Inactive ®Truck <br /> • Q End-Use ® Container <br /> Longitude - Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 I J <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 <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 FX7) <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/C-IWMB 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 /> Q Q1 Other: <br /> Comments G 'f�t s V10�tS � �Gt�tll)1f+ /N,1 Sit It <br /> Eoi1 ttila Ti--e ,iii re-�-ea Ce i /'I ) <br /> OYI_Y <br /> Inspection Form Included: Q r <br /> Comments Included: Q 10 �Y <br /> Business R s i nat a Phone Number Inspector's Sig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C-rrec Incorrect: X a ha P Ej 11121:3 <br /> White Cop :CIW Yellow Copy.Operator PigX Copy.LEA <br />