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09049040342 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> fill <br /> State of 8181 romle Survey Form - Pa el I 1 - 10883 6 0 <br /> Cgrated 1(New nage y 9 <br /> Gatlfomla Integrated Waste Management Board J . <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- VT� o 3 15 1 Li �� - LE Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local Soo �oay,k�� �DuiT}y If Referral,choose referral type(Fill one) <br /> Identifier: J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address <br /> I a II ND i <br /> Street <br /> L �C Inspection Date © i a / O 7 <br /> cityState 7_IP Coae I(,ikon J Time In Time Out <br /> City <br /> Business Rep TitleAM 0 AM <br /> i '. I ] :[ OP h 0 P <br /> Operational Status Tire Type Business Role 'Storage Type' <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r t I Active ®Passenger %Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned 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 Q Car Dealer Q Collection Q Crumb Rubber h <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other I-SMAP <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT—STAJTUS <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 /> 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 HaulersQ 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 C-ompliance - No Violations <br /> Q Q Other:�§ <br /> Comments <br /> u4Pro- �y 7-5-;te�s_ot�s i}e r� cal ►S-UOuN15_+�inn_wI <br /> osslnoW�4w) r u� —I-o v;_o_6►was <br /> Inspection Form Included:Q a <br /> Comments Include Z'd —,��-a <br /> Avec Rep's Signature Phone Number inspectors Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: & X Ai M P L E 1 '2 3 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />