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i�El <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r.° State°'Gal fomW I 1 10 8 819 8 <br /> CIWMB,fn IN-04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type (Fill one) <br /> Site Suffix: (� !Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: J O,y „�/ N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1 Inspected By Inspector <br /> Physical Address <br /> ( 20 5 0 <br /> Street <br /> Inspection Date <br /> I P.;?_'bia CA �53(.4_j <br /> City Slate ZIP Cade Time In Time Out <br /> Business Rep Title I O AM :m OAM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) A. (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I*Active Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other (��� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E_NI- RC-EMENT STATUS <br /> V A HAULING Nl3MANIFEST REQUIREMENTS Q Notice Ot violation 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§16459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required Ior NOV or FXTJ <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/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 /> 1010 1 Other: § <br /> Comments Q � <br /> r GIA+-G► LG3 <br /> �� l�(rt4er_,n_���1_ <br /> .A!4siTf I/Ain n.l P.b—._.J�l —Vii •rt•MaA4—at.a�//� Jit N lt.�r t .ALJ L-46_'!�—N� <br /> Inspection Form Included:Q <br /> Comments Included: <br /> usiness Rep's qSigYarure— Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK C eke• I t>orrec [EIXIAIMIPILIEI 111.2 3 62081 - <br /> ■ While Cop.CfWM Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> ( <br />